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37 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 O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT 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 5_1G tJ, A n.-(ne�S __. _ City �ex-��✓`— Lot Size/Acreage <br /> AeJ - <br /> Owner's Name (� -0 9_- Q_a--; �Address 2_L /V k (4A yS Phone 0� <br /> Contractor Address License No. It Phone <br /> 931 de <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEA ❑ Monitoring Well C7 <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 <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'I Public [I Other f'1 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 ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE El No. & Length of lines Total length/size N <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> S <br /> SEEPAGE PITS 11 Depth Size Number f <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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:"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 call forallrequired inspections. Complete drawing on re a side. <br /> Signed X 1��.fL 9— `ce..�• o�n�;�� Title: Date: <br /> F DERIWTMENT USE ONLY <br /> Application Accepted by d.m t�. o �- ,�:_ Date t ` Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin County Public Health �S <br /> Services, Environmental Health Permit/Services \' <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 C � <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> . EH13-24(REV.Iixs) <br /> EH 31.26 C, <br />