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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)468-3 A E C E IVE D <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> Ali6 Q 3 1999 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRCNMN�AppjjHEA �N <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install thePRLT�iYSi�'e's�A5. 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 <br /> Health Services. <br /> 154, <br /> wi;zj� <br /> Job Address �J �" `" -- �– City Lot Size/Acreage <br /> NOwner;s,Na <br /> Addre� Phone l <br /> r gessl�o t License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REP_LACEMEN ❑ DESTRUCTION ❑ Out of Service Well L) <br /> PUMP INSTALLATION ❑ SYSTEM REPA1 OTHER ❑ Monitoring Well C7 <br /> DISPOSAL FLO. <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 SEWER LINES PROP. LINE <br /> f�3�.• <br /> `-FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 5 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> 1"1 Public FI Other 171 Delta 44 Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx, Depth I I Eastern f Surface Seal installed by <br /> Repair Work Done L7 Type of Pump H.P. _ - State W Do / <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth _ _ Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITIaN l I DESTRUCTION 1 1 ave septic system permitted if public sewer is <br /> available within 200 leet.l <br /> Installation will serve: Residence— Commercial_ Other . <br /> Number of living units: Number of bedrooms <br /> 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg j Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: WellFoundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Fou`ndation Property Line <br /> ' f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well�{{ Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> - I'hereby certify that I-have prepared this application and that the work wiil be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homeowner or licensed agent's signature certifies the following:"1 Certify thatin_tha.performarice of.the.work.Jor which this permit.is-issued,_I shall not <br /> employ any peraon'in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fotlowing: "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 applicvrvust c requi d inspections. Complete drawing on re rse side. <br /> Sig e <br /> Title: Date: <br /> a FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> I90 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 1 <br /> Additional Comments: <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEMOUNT DUE UNT REMITTED CK RECEIVED BY DATE PERMIT'N0, <br /> INFO CASH <br /> . EH 13-24(REV.$/A5) �f .• I.7 Yf✓ a41 <br /> EH 14.20 r <br />