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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 0 BOA 2009, STOCKTON, CA 95201 <br /> A <br /> MIT <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicat a 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. j <br /> Job Address7 ZZ 6t/ City Lot Size/Acreage <br /> Owner's Name Paz na Address Phone <br /> Conlrat for Address E=icense IVo. �=Phone" �o' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I=1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDAT.IO.N_ _AGR ICULTU.RE.WELL_ OTHER.WELL. _PITS/-SU.MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Pnblic Ia Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation ^... Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ.�AIR/ADOITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> r r <br /> available within 200 feet.) <br /> Installation will serve: Residence__/ Commercial Other <br /> Number of living units: __/_ Number ofb droo IS <br /> Character of soil to a depth of 3 feet: Z L Water table depth <br /> rs <br /> SEPTIC TANK. Q—T'ype/Mfg Capacity__,L.A_C2a No. Compartments 1 <br /> PKG.TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation (/� Property Line <br /> LEACHING LINELYS. & Length of lines ,I T tpl length/size <br /> FILTER BED ❑ Distance to nearest: We Foundation r Property Line <br /> SEEPAGE PITS LL—Depth 5 Site Number <br /> SUMPS , Ll Distance to nearest. Well Foundation.74) I' Property Line by <br /> DISPOSAL;PONDS © h i <br /> I hereby certify that I have prepared this application and that the wofk will be done in accordance with San Joaquin county ordinal Ces, State laws, an <br /> 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 1 <br /> 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 work for which this permit is issued, I shall employ persons subject-to workman's-compensa- <br /> tion laws of California," <br /> The app2��,cantZl.Lil-If r a eq 'red ins do -C-o drawing on verse side. ,t ;`- <br /> Signed ills: _rl� Gr'�'��r pate: �� OE <br /> FOR DEPARTMENT USE ONLY } v '. <br /> Application Accepted by — <br /> Date P-2 c � V Area <br /> �y <br /> ,PiYor Grout Inspection by Date Zly 4� Final Inspection by y✓/� 4,j Data <br /> f/ r <br /> Additional Comments: ^r <br /> ' I <br /> Applicant - Return all copies to., San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE)NFO AMOUNT DUE AMOUNT REMITTED C K 11 RECEIVED BY ^�DAATE PERMIT NO.. <br /> + EH 13- (REV. <br /> tREV. i n Sl � ��^"' S 1 -�1 ./ <br />