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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> of ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT 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 ��ty40rdnance„N . 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Heaa�lth Services. R�'Job Address f-" rn �- � �` y Lot Size/Acreage �* �Cr�Z <br /> Owner's Name ( -���'�L Address /�O ,�v , �7�2 Phone <br /> Contractor.1—e- Address [' "�"J T'r/� +�i"( rL/ILicense No.1_53Q79 Phone!?-V—,4 <br /> TYPE OF WELL/P P: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> P LATION O SYSTEM REPAIR O OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL ELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC PECIFICATIONS <br /> n Industrial 0 Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [.l Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> 1'1 Public EI Other n Delta Depth of Grout Seal a of Grout <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material b Depth <br /> Depth Filler Material b Depth <br /> T�OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: encs_ Commercial_ Other <br /> Number of living units: r of bedrooms <br /> Character of soil to a depth of (feet: Water table depth a <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foun ' n Property Line <br /> LEACHING LINE 0 No. & Length of lines Tota th/size <br /> FILTER BED D Distance to nearest: Well Foundation Prope ne <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a <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: "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." / 7 <br /> The appli t I for 1 r quir. 1 specti plete drawing on r verse ide. I / <br /> Signed X Title: a 4"L Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by� 1�'\� Date 1,,/ � �y Area��� <br /> Pit or Grout Inspection by Date Final Inspection b;� \ _ , Datf / <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 <br /> INFO �AM/OUJNT DU/EE AMOUNT REMITTED CASH RECEIVED BY DATE PERma'rNO. <br /> . EH 13.21(REV.1/x sl }`tet ll ,� C c, V g �F <br /> EH i42a �1 <br />