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APPLICATION FOR PERMIT �� <br /> ` fi SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A <br /> 1 ENVIRONMENTAL HEALTH DIVISION lV <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> E/ P O BOX 2009, STOCKTON, CA 95201 <br />{ PERM11 EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Completer 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 /> i 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 Service . r <br /> CT <br /> Job Address ---I I ���� ----- ----- City C " Lot Size/Acreage <br /> Owner's Name v Address 0 +� V, o sac �+ Phone Z <br /> Contractor!`7 uJ U1 ��' Address License No. Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> { PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ l�anitoring Well ❑ <br /> E DISTANCE TO NEAREST: SEPTIC TANK fSEWER LIN Di5POSAL FLU, AROP. LINE <br /> FOUNDATION AGOICULTUR WELL OTHER WELL PI75lSUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO STRU ON SPECIFICATIONS <br />'F n Industrial ❑ Open Bottom C7 Manteca Dia. 1 Excavation Dia. of Well Casing <br /> F] Domestic/Private El Gravel Pack 0 Tracy Type Casing Specifications <br /> I'I Public Ia Other n Delta D /twl Grout Seal Type of Grout <br /> t I Irrigation —..Approx. Depth I I Eastern , urface 5 al Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> f Well Destruction ❑ Well Diameter Seal tlaterial 1' Depth <br /> t Depth Fi er Material & Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPA /ADDITION I I DESTRUCTION !No septic system permitted if public sewer is <br /> I *� available within 200 feet.) <br /> Installation will serve: Residence .X— Commercial_____ Other <br />! Number of living units: �� Number of bedrooms ^� <br /> Character of soil to a depth of 3 feet: YLfh'1Vte 1 Water table depth " <br /> SEPTIC TANK. ❑ Type/Mfg C jt�.j,irP` Q.-.-- -- Capacity -- No. Compartments <br /> PKG, TREATMENT PLT. ❑ C , Method of Disposal , <br /> Distance to nearest: Well 1 Foundation Property Line t op, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <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 subcontracting 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 /> T <br /> he applican t call for all required inspections Complete drawing on reverse side. <br /> X Title: Date: �1� <br /> PARTMENT USE ONLY <br /> Application Accepted by Date 3� Area <br /> Pit or Grout Inspection by Date Final Inspection by ' Date ,3 <br /> a <br /> Additional Comments: tZA <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 S. Hazelton Ave., Px 2009, Stockton, CA 95201 <br /> t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. \\Z1 <br /> INFO ASH <br /> � EH 13-24 MEV.1/nal <br /> �3� <br /> �� 00 r /2 ke) 47_1? <br /> { EH 14.29 ' <br />