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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLI!rC HEALTH SERVICES <br /> Y, ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-•3420 <br /> P O BOX 2009, STOC&TON, CA 95241 <br /> PEMIT EXPIRES 1 YEARIFROM DATE ISSUED <br /> (Complete in Ttiplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> San <br /> application is made in compliance with San Joaquin County Ordinanceallo. 51+9 and 1862 and the Rules and Regulations of, <br /> Joaquin County Public Health Services. I <br /> rD� w. s 0City Lot Size/Acreage O l7 <br /> Job Address <br /> Z� 4 �dr Phone <br /> Owner's Name e k. <br /> Moore Address I <br /> Contractor ✓ Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT l l DESTRUCTION ❑ Out of service Well 0 <br /> Monitoring well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER <br /> 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE. <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS <br /> C:1 Industrial ❑ Open Bottom 'O Manteca Ria. of Well Excavation Dia. of Well Casing <br /> # p SpecificationsTyPe of CsingC1 Domestic/Private ❑ Gravel PackL] Tracy <br /> I'i Public <br /> C1 Other [-1 Delta Depth of Grout Seal t Type of Grout. <br /> � -,. <br /> It I Irrigation Approx. Depth l I Eastern Surface Sehai installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done , <br /> ' Welt Destruction ❑ Well Diameter <br /> Sealing Material',& Depth <br /> Depth Filler Material,& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION IJ DESTRUCTION I I.(No septic system permitted if public sewer is <br /> i available within 200 feet.I <br /> Installation will serve: .Residence Commercial-Z •Other r <br /> Number of living units: Number of bedrooms t r <br /> Character of soil to a deptD of 3 feet: <br /> Water table depth <br /> SEPTIC TANK Type/Mfg L Capacity - No. Compartments <br /> .11 <br /> PKG. TREATMENT PET. ❑ • r: < <br /> Method of Disposal <br /> Distance to nearest: Well Foundation 7 ___ Property Line ESQ _ <br /> LEACHING LINE No. & Length of lines x'f Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel! ` Foundation Property Line <br /> SEEPAGE PITS Ivan 'Depth J S' —Size _ -Number <br /> SUMPS Ll Distance to nearest: Well 2 ,00 Foundation yD - Property Line <br /> DISPOSAL PONDS ❑ t I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 4 rules and regulations of the San Joaquin County <br /> !t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to'become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this,permit is issued,'I shall employ persons subject to workman's compensa <br /> ., tion laws of California." p j. <br /> l The applicant m �r all required inspections. Complete drawing on reversle side. <br /> f. Y -� T <br /> Signed X Title: �] ���A r - __ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date �I _ Area <br /> Pit or Grout Inspection by ate Ft el Inspection by Date j0 <br /> Additional Comments: <br /> H, r <br /> Applicant - Return all copies to: San Joaquin County Publ c Health <br /> Services, Environmental. Health' Permit/Services <br /> f 1601 E. Hazelton Ave., F 0 Boi` 2009, Stockton, CA 95201 ' <br /> - Ih <br /> ICK 9 <br /> FEE AMOUNT DUE AMOUNT'REMITTED CASH I!,� RECEIVED BY PATE PERMIT NO. <br /> INFO /���7� } 'ty1 <br /> EH 13-24{REV.t/n SI ` ,t�J 14 <br /> �l.J t 1 •` �-• l ` <br /> EH 14.26 ` IIS! <br />