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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pgMITEXP RES 1 YEAR FROM D E ED <br /> (Complete in Triplicate) <br /> I Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Sen Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> t� City� Lot Size/Acreage <br /> r <br /> Job Address ZL <br /> O , Address <br /> Phone <br /> Owner's Name <br /> Address License No. Phone <br /> Contractor- F =— <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> TYPE OF'WELL/PUMP: NEW WELL El <br /> OTHER 0 Monitoring Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRtiO_, <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES ' `*DI,SPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL oTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial [D Open Bottom © Manteca Dia. of Welt Excavation <br /> Dia. of Well Casing <br /> P Domestic/Private ❑ Gravel Pac.k `*,' L7 Tracy• .�V,f..Type of Casing <br /> I . Specifications <br /> 1 1 Other F1 Deltay Depth of Grout Seal .__ Type of Grout <br /> I'1 Public . <br /> Surface Seal Installed by <br /> I I Irrigation �.A0pApprax, Depth I I Eastern .�` '� <br /> H Pj,� <br /> State' <br /> Work Done <br /> Repair Work Done ❑ Type of Pump } r: <br /> ` Sealing Material & Depth j <br /> Well Destruction ❑ Well Diameter k •. .-— i OQ <br /> Depth '�';Filler-Mate rel & Depth <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATiON 1 I REP.AIR/A•DDITION- —DESTRUCTION I I (No septic system permitted if public sewer is � <br /> t ` ,fj pvaiiable within 200 feet.) <br /> installation will serve: Residence y Commercial Other ` -� <br /> Number of living units: 1— #Number of bedrooms_ „: <br /> Character of soil to a depth of 3,feet: - "t Water table depth ., <br /> - rapacity ' No. Compartments <br /> 1 SEPTIC TANK ❑ Type/Mfg r --- <br /> PKG. TREATMENT PLT. ❑ ! Method of Disposal <br /> i "" <br /> Distnceto nearest: Well ' j ,r - Foundation -s 'Property Line - <br /> a ° t i <br /> LEACHING LINE 0 No.1& Length of lines t �t Total length/size _ r <br /> FILTER BED ❑ Distance to nearest: Well Foundation 1�9 {Pro erty Line _ "S <br /> i f <br /> SEEPAGE PITS I ) Depth Size Number ' <br /> SUMPS LIante to nearest: Well Foundation—a* !Property tine <br /> DISPOSAL PONDS"" °_ � - ." '. "cam - f� <br /> I hereby certify that I have prepared this application and or will a done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County., <br /> Home owner or licensed agent's signature cert ifies,the-following:"I'certtify that in the pe5rlormance of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject.to workmen's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the wor..Jor_which-this-pe(.mit.is-issued,)shall employ persons subject to workman's compensd <br /> tion laws of California. <br /> The applicant m t c II for all aqui d in ctions. Complete drawing on reverse side. <br /> Signedda <br /> Title: — Date: <br /> Vw_ <br /> R�PAR�TMENT�USE NLY <br /> ;Ap;plfition�Accepted by Date Area 12 <br /> �1� <br /> ,� Date Final Inspection by DateZL 1_. d <br /> roux ction by <br /> Additional Comments: - u <br /> Applicant - Return all copies to: San Joaquin County Public Health® <br /> r Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 �} <br /> FEE AMOUNT DUE AMOUNT REMITTED jo�RECEIVED BDATE PERM11,NO. <br /> Cy <br /> CASH t lJ <br /> INFO <br /> . Er ta•zi rREY.r h s) a <br /> 7/-,�4 h �o <br /> a< EN 14.20 <br />