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APPLICATION FOR PERMIT <br /> Q v- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1 I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PE MIT EXPIRES 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 the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City. Lot Size/Acreage <br /> 1.�r / <br /> Owner's Name� JL 1& p�L r Address Phone a2 co/ <br /> Contractor ` Address License No. 7cPhone <br /> TYPE OF WELL/PUMP: NEW-WEL-L O — -----WELL REPLACEMENT ❑ =DE TRUCTtON-LI Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OXFiER WELL- PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO14 SPECIFICATIONS <br /> n Industrial O Open Bottom O Manteca Dia:of Well Excavation Dia.'of Well Casing <br /> C:1 Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> f'I Public fl Other n 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 U Type of'Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth F4.11er Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ACSDITION ( DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial 2 Other <br /> Number of living units: ___L Number of bedrooms <br /> Character of soil to a depth of,3 feet Water table depth <br /> SEPTIC TANK GYType/Mfg Vic Capacity W No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 C.�a�� ( Method of Disposal <br /> Distance to nearest: WBTt Foundation Property Line , / <br /> a <br /> LEACHING LINE Cl No. & Length of lines - -- Total length/size <br /> FILTER BED fel—Distance t9 nearest: Foundation ! Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit isissued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicar#-must call for all required spe tions. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> PARTMENT USE ONLY <br /> Application Accepted by ��Sww �Q� -M <br /> a CLb&a.ft. Date <br /> Pit or Grout Inspection by Date Final Inspection by 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 0 Box 2009, Stockton, CA 95701 <br /> INFO FEE AMOUNT DUE <br /> AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. <br /> . EH 13.211NEV.r/X51 ��,�/ i �- 0G jZ+ � 7-1-91 <br /> EH A-211 1 ll l <br />