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t 1 APPLICATION FOR PERMIT <br /> 1 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ZFAMIT EXPIRES I YEAR FRQM DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulesand R tions of San <br /> Joaquin County Public Health Services ` r <br /> Job Address6City I,ot Size/LAper�eage /' <br /> Owner's Name —-_ - _ L • ��°Address 11 ( 3 N Phoney IY <br /> �]�)) <br /> Contractor /ff4 <br /> ddress t=License.No. Phone <br /> TYPE OF WELL/PUMP: f .NEW- LL © WE L REPLACEMEFT E-1 DESTRUCTION ❑ Out of Service Well ❑ <br /> v <br /> PUMP INSTALLATION ❑ YSTEM AIR ❑ OTHER ❑ Monitoring Well ❑ <br /> b <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i <br /> P <br /> FOUNDATION'.' AGRICULTUR W5eL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS 1{� <br /> E industrial ❑ Open Bottom L].Manteca- . i .-of-Well--Excavation r v <br /> \ <br /> fa <br /> Domestic/Private ❑ Gr*vel Pack y ❑ Tracy T e of Casing — Specifications <br /> I'I Public C] Dther Cl Delta 0 pth of Grbut Seal'1 ._-__4 F Type of Grout r _ <br /> i I Irrigation `�.Approit"Depth I );East Su ace Soul Installed`by <br /> Repair Work Done 0 Type of,Pump', e f•P ° Q State Work Done_ <br /> Well Destruction ❑%? Well Diameters - Sealing Material &_Depth " <br /> Depth _Filler Material & Depth'` r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 1REPAIRJADDITION I I DESTRUCTION I I lNo septic'system permitted if public sewer is <br /> ';available.'within 200 lest.I <br /> Installation will serve:' Residence_ Commercial cher <br /> .J w _n 1 <br /> Number of living units: Number of bedroom r <br /> Character of sail to a depth of 3 feet: Water,table depth <br /> SEPTIC TANK 1 ❑' Type/Mfg Capacity No. Compartments ! <br /> PKG. TREATMENT PLT. ❑ Method of Dispos <br /> Distance to nearest: r Well Foundation Property-Line <br /> LEACHING LINE Ll No. & Length of lines C ` 0 t To I length/`size <br /> FILTER BED ❑ Distance to nearest: Well Foundation v- Prot y Line <br /> SEEPAGE PITS I I Depth Size Number <br /> i <br /> SUMPS LI Distance to nears t: Well Foundation "Property Line <br /> DISPOSAL PONDS ❑`- ^ <br /> I hereby certify that I have prepared this apolication 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 of•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 subs+ct to workman's compensa- <br /> tion laws of California." t r <br /> The applican ust Call for require inspections. Complete drawing on reverse side, ' <br /> r ' r <br /> Signed Title: <br /> FOR PARTMIENT USE ONLY <br /> Application Accepted by Date �4 Area <br /> Pit or Grout inspection by t Date Final I Inspection by } Date / ! <br /> Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services;Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> CH 1 i EH t4. eREV.t i n si %+�7 <br />