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APPLICATION FOR PERMIT <br /> SAN •TOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009 STOCgTON CA 95201 �4 <br /> PEYWIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri ed. This <br /> I 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 /> :.- -yam .� S <br /> Job Address / s GoG �1� / City 7 6C4� 'r?l�ot Size/Acreage �sp <br /> Owner's Na a -Lf kv <br /> �`'~AtldY�ss _ Phone <br /> Owner's Na 14 <br /> Contractor_ __ rAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ e OTHER ❑ Monitoring Well C.3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T DISPOSAL FLD, PROP. LINE <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ r <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth _ <br /> Depth Filler Material & Depth pC� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION i I DESTRUCTION-1.1INo-septic-system permitted if public sewer is <br /> 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 TANK ❑ Type/Mfg TMJ_ __ _ ________ 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 ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS -•�^^ "-f 1 Depth T Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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 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." Cantractor's hiring or subcontracting signature <br /> M, certifies the following: "1 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 Califo a. <br /> The applicant st cat for all req nspections. Climple a drawing on reverse side. <br /> Signed Title: <br /> g '�, L . ���, �/ Date: `r f <br /> FOR DEPARTMENT USE ONLY q ry <br /> Application Accepted by V-6 a_ �t1 '�_ Date Y � 1 Area <br /> Pit or Grout inspection by Date.^ Final Inspection by . c Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE OUNT REMITTED CASH RECEIVED BY OATS PERMIT'NO. <br /> . EH 13411REV,tiH51 <br /> EH 11.2a <br />