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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)468-3420 .amu i <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s 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 /> iso , c�!1;ey <br /> Job Address A � 1/�- �� Cit Lot Size/Acreage <br /> i <br /> Owner's Name f!2` At>L@L- f?7f'1` Address 30phone `moo G—fig <br /> Contractor"A7:E,—7:E,- 5l! r+ —Address '7,"1 F, ?11AXJ D-/1417A License No. Phone ! <br /> TYPE OF WELL/PUMP: _ NEIN WELL.-C `" a .-WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well Cl <br /> µ 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. oLWell Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public 1:1 Other F� Delta Depth of Grout Seal Type of Grout <br /> 4 <br /> I 1 Irrigation _Approx.. Depth; [ I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump } H.P. State Work Done <br /> Well Destruction ❑ Well Diameter k e"• Sealing Material & Depth <br /> Depth ,. Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted.if public sewer is <br /> available within 200 leet.l <br /> Installation will serve: Residence Commerciai_ Other <br /> Number of living units: Number of bedrooms . . i <br /> Character of soil to a depth of 3 feet: w Water table depth t r� <br /> SEPTIC TANKType/ 48'.1 l Capacity—/4�O No. Compartments ��7 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wellc30 Foundation S Property Line G <br /> LEACHING LINE L1 No. & Length of lines.-.13 Total length/size <br /> FILTER BED 0 Distance to nearest:, Well Foundation Property Lin 1 <br /> SEEPAGE PITS 11 Depth Size Number 1 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 7 <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 /( <br /> rules and regulations of the San Joaquin County h <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which_this.pe"it 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 compens4< <br /> tion laws of California." j <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X.� r` Title: _7'� JJ^"� �}0 7 <br /> �- Date: <br /> F EPARTMENT USE ONLY <br /> Application Accepted by Date' Area v 1 <br /> Pit or Grout Inspection t Date Final Inspection by. Date e ,Z) <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Inavironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> « EH 13-21 MEV.%/"S) 1!'-y r O 0 f 7 r 8 +� '7 CID l�� i <br /> EH 21.2E <br />