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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 /> PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED } <br /> &r1a <br /> lete in Triplicate) <br /> A licatibn`is here made toGSJoaquin Counpp by permit to construct and/or"install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public H alth Services. , <br /> Job Address � r1 City C Lot Size/Acreage <br /> Owner's Name 1 r tnd '`u'f' �D• Address ! _ Phone <br /> Contractorrv�441kA41A.- Address 4 ZS �T9�+�J�ILicense No. S Phone S f <br /> TYPE OF WELL/PUMP' NEW WELL 0WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well D t <br /> r LL <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � lJponitorin g Well <br /> L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL FLC PROP. LANE evn h <br /> FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/sum PJ <br /> .� .'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION (( <br /> -11 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation— . Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing Specifications <br /> I') Public El Other n Delta Depth of Grout Seal Type of Gr in <br /> I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by ky&Z 94ZAV& LW P <br /> Repair Work Done 0 Type of Pump H,P. State Work Done <br /> Well Destruction 0 Well Diameter sealing Material & Depth <br /> f Depth Filler Material & Depth <br /> TYPE,OF SEPTIC WORK:, NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ' r 'Installation will serve: Residence_____ Commercial_ Other <br /> '* Number of living units: Number of bedrooms <br />° Character of soil to a depth of 3 feet: µ Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> - Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 1=1 Distance to nearest; Well Foundation Property Line <br /> f SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> F rules and regulations of the San Joaquin County <br /> 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 Californi ' <br /> The applicant m l Jof all required ' s omplete drawing on reverse side. <br /> Signed Title: r Date: 7 .3/17 <br /> FOR DEPARTME T USE ONLY <br /> Application Accepted by_ Date ,f / Area <br /> Pit or Grout Inspection by Date Final Inspection by �1� (�� Data 7 � <br /> tr' <br /> Additional Comments: <br /> Applicant •- Return all copies to: San Joaquin County Publ c Health r <br /> _Services,;Environmental Health Permit/Services - <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> E5927 <br /> AMOUNT DUE ANFOMOUNT REMITTED CAS Ii RECEIVED BY DATE PERMIT'NO. <br /> EH a-ie rAty., N s, 'y 17 <br /> r <br />