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{ F APPLICATION FOR PERMIT f <br /> ffff SAN vwn%g N COUNTY PUBLIC EEALTH SERVICES <br /> ENVIROI�A!ENfiAL'CHEALTH DIVISION <br /> 1601 E. HAZELTON'AVk� ,' PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIX w <br /> RES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 San Joaquin County Ordinance No. 549 and 1862 and th_e Ru$s and Regulations of San <br /> Joaquin County Public/Health Services. 4?" /1 <br /> Job Address0 WCity Size/Acreage <br /> Ir c �{ �] <br /> owner's Name T/�1_ Ze�� Address I w" �e� �' i phone 3` 2�� <br /> tliA gs�� �s7 1232 <br /> Contractor � i�� Address Q License No. Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> :yt ',i PUMP INSTALLLAATION-g——SYSTEM-REPAIR�D OTHER O Monitoring Well E� <br /> DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES DISPOSAL FLD. PROP. LINE _ r <br /> \_. FOUNDATION a .AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIONS <br /> f_-1 industrial ❑ Open Bdttom. C3Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Ci Gravel Pack 0 Tra Type of Casing specifications <br /> #'l Public 17 Other_•I"J elta Depth of Grout Seal Type of Grout r � <br /> I I Irrigation \__1 Approx. Depth I East rn Surface Seal Installed by <br /> Repair Work Done U 4�T' of Pump State Work Done <br /> Weil Destruction ❑ Well Diameter; ealing Material 6 Depth <br /> Depth Filler Material b Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is r� <br /> I ^:a available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet. Water table depth <br /> SEPTIC YANK, ❑ T Mf f`-' <br /> Type/ g `Capacitty. _ �•,�,.,� No. Compartments <br /> PKG. TREATMENT PLT. Clt f <br /> �W_� � Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line t a <br /> 1 d + 3 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearestu Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size, Ott 1�Numlier- <br /> SUMPS Ll Distance t t nearest: Well Foundation .. _Property Line I r� <br /> DISPOSAL PONDS ❑ <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 /> rules and regulations of the San JoaquinlCounty t <br /> Homeowner or lice gent signature certifies the following: "I certify that in the performance of the work for which this permit is issued,'l shall n6r <br /> employ any perso such man er as to tiecome sub' o workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifiea the foll ing: "I certit at in t r to the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of liforni r <br /> The applic t must or II requi omple (awing re side. <br /> 1. / <br /> Signed XTitle '� t ! <br /> g : Dale: <br /> F DEPARTMENT USE ONLY <br /> ry <br /> Application Accepted bytAA Qc_ ADate Area <br /> Pit or Grout Inspection by Date Final.Inspection ate o <br /> _�.. <br /> Additional Comments; ��_ <br /> fit z�Z. r�•y at'4 tea`"±`w . <br /> Applicant - Return a12 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EH t3-241REV.rins) <br /> EH 34.25 t 0 p (7 <br />