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APPLICATION FOR PERMIT <br /> SAN dOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM-DATE U_$,5 TMMM <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. 00, <br /> r # <br /> Job Address � City Lot Size/Acreage <br /> Owner's Name Aa* FIFO ess Phone r� <br /> Contractor ddress cense No. 7ePhondq2/0,14 <br /> l o <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3 Monitoring Well €� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Co <br /> I <br /> * Industrial C3 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications <br /> I'1 Public C7 Other fl Delta Depth of Grout Seal Type of Grout ,- <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by r <br /> Repair Work Done U Type of Pump H.P. State Work Done_ U <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth y� j <br /> 1, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION III REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is rr�" <br /> available within 200 festJ <br /> Installation will serve: Residence e Commercial— Other <br /> Number of living units: 4- Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ _ _Z fr Water table depth s <br /> SEPTIC TANK. ❑ Type/Mfg Q!� - , Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ T Method ofDisposill <br /> d� <br /> Distance to nearest: Well Lo Foundation Property Line_�___��! D <br /> LEACHING LINE 0 No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well , Foundation .F] Property Line T <br /> SEEPAGE PITS - 11 Depth"a/` L b- i e _ Number <br /> SUMPS la Distance to nearest: Well a r� Foundation- Property Line 0 i <br /> DISPOSAL FONDS ❑ <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 I <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." Contractor's hiring or sub-contracting signature l <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 applicant must ail MR 'ad insPe.ctions. omplete drawing on reverse side. <br /> Signed X Title: Date: + <br /> T3 DEPARTMENT USE ONLY ' <br /> Application Accepted by Dater-i Area <br /> Pit or Grout inspection by Date-- Final Inspection by���1�—� Date { -z w <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 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> a EH13-24[RFV.rinsl ��� II ZJ�iV� 11oz <br /> 3 <br /> EH 71.20 <br />