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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> r <br /> PERMIT EXPIRES !—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 the Rules and Regulations of San <br /> Joaquin County Public Health Services. .� <br /> lob Address City Lot Size/Acreage -- _ <br /> Owner's Name Address f� Zz. �_ _ Phone <br /> �ContracIorfZ c711f Pj=U Add�ess� 4O R',3r,.c.Q,v gl7- SGy-L17license-No. Phone <br /> TYPEFOF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT,i'J t DESTRUCTION ❑ Out of Service Well C1 <br /> A. ` PUMP INSTALLATION ❑ [ SYSTEM EPAIR ❑ + s + OTHER ❑ Monitoring Well LJ <br /> '. r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LINES DISPOSAL FLD. PROP. LINE " <br /> I FOUNDATION AGRIC TUBE W LL �n 0-THER WELL--PITS/SUMPS <br /> INTENDED USE TYPE YOF WELL PROBLEM AREA C STRUC710N SPECIFICATIONS <br /> n industrial ❑ Open Bottom "'( -Manteca is. of Wel! Excavation ' Dia. of Well Casing <br /> II Cl Domestic/Private ❑ Gravel Pack L7 Trac T e of Casing ` <br /> Y YP g ~"""- "� Specifications <br /> !'1 Public Cl Other n Delta eptGrout Seal Type of Grow <br /> I I Irrigation Approx. Depth I 1 Eastern S ace Seal Installed,by <br /> Repair Work Done 0 Type of Pump H.P.. State Work Done _ <br /> ! Welt Destruction 0 Well Diameter Sealing Mate ial & Depth <br /> y <br /> Depth Filler Materi & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> L( I <br /> ation will serve: Residence_ Commercial__,_.,•. Other <br /> er of living units: .,.Number_af bedrooms, <br /> 1 <br /> cter of soil to a depth of 3 feet: <br /> Water labia depth <br /> TANK. {a 'Type/Mfg y Cbpacity No. Comp�ments <br /> EATMENT PLT.Ll ! Y t Method of Disposal <br /> Distance to nearest:' Well c .-- `•f` Foundation-- c� Property Line � <br /> G LINE ❑ rNo. & Length of fines _ " a� a% ""�" L�C7 �y t <br /> _ Total length/size <br /> ED ; 0 Distance to nearest: Well Foundation Property Line <br /> EPITS j ( I Depth Size NumberCI Distance to nearest: Well Foundation Property Line �L 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, an <br /> rules and regulations of the San Joaquin County - <br /> Home owner or licensed agent's signature certifies the following: t <br /> "I certify that in Itis performance.of the work for which this permit is issued, t 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." --"w-.:=".�+ <br /> t The applicant must call for all required ins <br /> � q pections. Complete drawing on reverse side. <br /> Signed V or Title: ---t Date:01 <br /> OR DEPARTMENT USE ONLY y'F <br /> f Application Accepted by ei 4.-7 ;'2- � <br /> Date Area <br /> Pit or Grout inspection by Date Final Inspection by Dated <br />! Additional Comments: <br /> t <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. AMOUNT-DUE AMOUNT REMITTED — - - " <br /> INFO' "RECEIVED BY" OATE PEAMI7"NO. <br /> CASH <br /> + EH 13.25 iREV.I/n Sl <br /> EH 14-25 __76 <br /> O 37s tl �' <br /> l 1 <br />