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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 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DA <br /> (Complete in Triplicate) <br /> i <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 a.nd Regulations of San <br /> Joaquin County Pqip Health Servic <br /> •� .-. City Lot Size/Acreage <br /> Job Address ` <br /> f "t <br /> t "Address Phone <br /> Owner's N a � � <br /> WILD, �- E Phone <br /> 1 Conlracl r Address License N . <br /> YPE OF WELL/PUMP: _vy NEW WELL ❑ Y � WELL REPLACEMENT Cl – DESTRUCTION L-1 out of Service Well ❑ 3 <br /> �.....-..�..-..�•..-•----w -�-. " torir3g'"WeTl"'C� !` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 � OTHER ❑ NS <br /> DISTANCE TO NEAREST: SEPTIC TANK'— SEWER LINES DISPOSAL FL:�,PITSI <br /> LINE <br /> FOUNDATIONI AGRICULTURE WELL OTHER WELL SUMPS <br /> SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI ONS <br /> F1 Industrial ❑ pe � . _ <br /> ❑ Manteca Diaof Well ion Diaof Well Casing <br /> r <br /> 1 <br /> f:1 Domestic/Private . ❑ Gravel Pack � ❑ Casing 9 Specifications <br /> l'I Public 1-1 Other _ ❑ Delta Depth of Gro Type of Grout <br /> I I tnigation Approx. Depth aitern� Surface Seat Installed by <br /> Repair Work Done ❑ &Type of P H.P. State Work Donee v <br /> :Sealing Material Depth' <br /> Well Destruction ❑ iameter.,y -_. <br /> Depth u Filler Material & Depth <br /> TYPE of: SEPTIC WORK: NEW INSTALLATION I I REPAIfllAODITION i l DES7fiUCTtO I (No septic system permitted if public sewer.is <br /> available within 200 feet.1 a <br /> Installation will serve: Residence— +Commercial ;Other <br /> Number of living units: ` Number of bedrooms -? <br /> Water table'depth r <br /> Character of soil to a depth v(.3 feet: '!� r`r�� ,. r ! <br /> Capacity No. Compartments <br /> SEPTIC TANK ""0 Type/Mfg r.; f° <br /> PKG. TREATMENT PLT. LI x f ; may- ` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line s <br /> LEACHING LINE D No. & Length of lines ° Total length/size <br /> j"" # (Foundation Property Line <br /> FILTER BED C1 Distance to nearest: Well <br /> SEEPAGE PITS I I :Depth Sire Number �n <br /> 1- IJJy <br /> SUMPS D Distance to nearest: Well 1Foundation Property Line rl <br /> DISPOSAL PONDS ❑ x <br /> 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 I I - <br /> Home owner o ensad agent's signature certifies the fallowing: "I certify,that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe in such manner as to bac a subject to workmen's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the foil ing: "I certify that i ormence of the work for which this permit is issued, I shall employ persons subject to workman's cor6pensa- <br /> tion laws of ii enia." <br /> The t us call for all r i i ins ctio .'Co plot <br /> Date: <br /> T S ed Title: <br /> _ 1 i <br /> FOR DEPARTMENT USE ONLY I ( 4 <br /> Application Accepted by <br /> ' Date <br /> Pit or Grout Inspection by Date $ Final Inspection by <br /> Additional <br /> e- <br /> Additional Comments: t <br /> F <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> k Services, Environmental Health Permit/Berviees <br /> [ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 , ( <br /> FEE AMOUNT DtrE AMOUNT REMITTED –CASH <br /> CK d RECEIVED BY DATE PERMiT'NO. <br /> i <br /> INFO y _ 1 (�` tf�� !i may{ <br /> f £H t3-Z4 1AEV.1;w 51�y ) 1...t•� •�, r R l ` ` O <br /> £H 74-2a 1✓ 111 - <br />