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APPLICATION FOR PERMIT <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MACHADO <br /> j P O BOX 2009, STOCKTON, CA 95201 247 N.Jackfone Road <br /> �cPeR, )tlPERMIT EXPIRES 1 YEAR FROM DATE ED Stockton, C8100rnia 95215 <br /> 1_ ,v (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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 9-110 13 1139 0) V City r_ _ + Size/Acreage <br /> 44 Owner's Name "` Address CA. - -e , Phone <br /> 1 <br /> Contractor 106-C VLA C� Address .r 2 License No J�S Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT C] DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ;W OTHER O Monitoring Well L7 <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 pia. of Well Excavation Dia. of Well Casing <br /> W"Domestic/Private Gl Gravel Pack 0 Tracy Type of Casing Specifications_- <br /> [') <br /> pecifications i'i Public (.1 Other ❑ Delta Dept of Grout Seal Type of Grout <br /> --- <br /> I i Irrigation N Approx. Depth I I Eastern Su ce Seal Installed by <br /> Repair Work Done ? Type of-Pump H.P, State Work pone 1 <br /> Well Destruction"' C❑ Well Diameter Sealing Material & Depth11, <br /> Depth Filler Material & Depth Q <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I Z iNo septic system permitted it public sewer is <br /> ((( savailable within 200 feet.) <br /> installation will serve: Residence_ Commercial— Other k } <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: )" - Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity i No. Compartments <br /> PKG. TREATMENT PLT. ❑ •� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING UNE Ci No. & Length of lines ` <br /> g Total length/size <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty'Line <br /> i <br /> SEEPAGE PITS i I Depth Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation 7` 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 workmen'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 compere <br /> tion laws of California." <br /> The appli t call for all r ked ins ctions. Complete drawing on v se side. <br /> Signed Title: Ze <br /> Date: <br /> ARTMENT USE ONLY <br /> Application Accepted by pate — — res <br /> 3 <br /> Pit or Grout Inspection b <br /> pe Y Data Final Inspection b Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Ftvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> INFO CASH DATE PERMIT*NO. <br /> EHA-20 <br /> i�-2e <br />