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APPLICATION FOR PERMIT 6LD L 0� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> j1 ENVIRONMENTAL HEALTH DIVISION &C-bX D <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IOUED <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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. t <br /> Job Address S c` f` _ City t,• Lot Size/Acreage <br /> .1 � <br /> Owner's Name �`� '✓�''� _ Address - 'y✓7 1L� Phone <br /> ],rte'\J� C I <br /> Contractor <br /> -------�F� „X/"'� Address .�7 � _. E.-y'�"P"'-(License N0�i S�l« S Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public Cl 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 ❑ Well Diameter Sealing Material & Depth t *� <br /> Depth Filler Material & Depth V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f� <br /> vl <br /> — <br /> LEACHING LINE ❑ No. & Length of lines Jotal 1.4ngth/size <br /> _ <br /> FILTER BED ❑ Distance to nearest: Well r Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number _ <br /> SUMPS Ll Distance to nearest: Well_ 146-Foundation 0 � Property Line � <br /> DISPOSAL PONDS ❑ Q) <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 V. <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 call f r all tre ' speoions. Complete drawing on reverse side. <br /> Signed X Title: Date: ' t� <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted byL �i Date_–< �.� Area <br /> Pit1or Grout Inspection by 1�' �"""'TT Date��i�inal Inspection by Date <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin Bounty 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 I CK RECEIVED BY DATE PERMIT'N0. <br /> INFO 6CASH <br /> . EH 13.24(REV.I/"a) <br /> EH Y l t I l-7 <br /> 11.26 <br />