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APPLICATION FOR PERMIT <br /> SAI ,JOAQUINe.COU4TY PUBLIC_HEALTH.. <br /> ��y ENVIRONMENTAL HEALTH DIVISION <br /> ff 1601 E. HAZHLTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE -J,s$,SUED <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 cott>pliance 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 a City, Lot Size/Acreage, <br /> Owner`s'Narne O 6� _CT! a.-�[1� $.3 —g02f <br /> �`T-T��'����_..� Address � _ Co�C3 �;�,„ _ �YPhone k <br /> Contractor A,2, [1GL Address_RQ, A!22-d,4 License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 'D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Noni boring Well C7 <br /> DISTANCE TO INEAREST, SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> { FOUNDATION AGRICULTURE. EL-L a '---NO;HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> H Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />'1 El Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Public i-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ^_Approx. Depth I I Eastern Surface Seal Installed by 1M _ <br /> Repair Work Done U Type of Pump H,P. "\4 Stare Work Dona r Ib <br /> Well Destruction ❑ Well Diameter Sealing,Naterial & Depth r <br /> Depth Filler Naterial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-t'I� REPAIR/ADDITION DESTRUCTION I i INo septic system permitted if public sewer is <br /> available+within 200 feet.) <br /> Installation will serve: Residence i� Commercial—, Other ' ! <br /> Number of living units: 4-f-- Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth i <br /> ❑ Type/Mfg t" Capacity No.!Compartments �M W <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> { Distance to nearest: Well Foundation i- Property Una <br /> �- 3 LEACHING LINE ❑ No. & Lengih`of lines Tptal length/size <br /> l=.� II <br /> FILF�R BED Distance to'a cast: Well4y �Foundation� Property Line _ t9 <br /> SEEPAGE PITS i r` �[,I_Depth" *`�J, Size "_ rNumber i <br /> { <br /> SUMPS Cl Distance to nearest,,. "*'Well Foundstion4,� Property Line I <br /> DISPOSAL PONDS ❑ 11. t- <br /> I hereby certify'that I have prepared hisjap0icafion^aiid thai,ifie-work will be done in accordance with San Joaquin county ordinances, state laws, and i <br /> rules and reguli�tions of the San Joaquin County„ ; ,� ; { { <br /> Home owner or licensed agent's signature certifies the following: "I certioyj'b'at 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,workmari's compensatio6 laws of California." Contr'actor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in itie psrforrn&i a of ti{te work for which th`ispermit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for-aU:� mp <br /> uire�if-inspections.-Colete{-drawirtig on reverse side. <br /> ## I� <br /> Signed X # .sem Title: d -^' <br /> ' Date: <br /> ­FOR-eOEPARTMENT,U_*�E ONLY <br /> Application Accapted'byDate Area <br /> Pit or Grout Inspection by Data Final Inspection by f i Date <br /> Additional Comments: .EGk �M <br /> Applicant - Return al1 coples to: San Joaquin County,Public Hetuth f �O <br /> -z-- , <br /> �-k— --• - - •-'�'^����-:�Serviccs,'Eavirotimental-Health '""� <br /> 1601 E:Hazelton Ave.;P 0'Boz 2009;Stockt'on;'CA'"`95201---"" ''"t"`a-.""".FEE <br /> 0 <br /> INFO MOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED I3Y DATE PERMIT'NO. <br /> • EH 1324 IREV, <br /> EN 842a <br />