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APPLICATION FOR PERK[T T <br /> 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 /> PEUIT EXPIRES 1 YEAR FROM 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 Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> � <br /> Job Address .�1�t/ 'T4+ S RAd D'i' R b _ City L-OC�teC plot Size/Acreage DAC Owner'sName tLEP LE LE Address SA"14- Phone <br /> Contractor Fytz if. WOOD Address ADSL License No. Z y7G Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well D <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 /> L-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> I'I Public f:7 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ^.Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other AG <br /> CQ <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 Y"L Capacity 44 2 No. Compartments <br /> PKG. TREATMENT PLT.❑ r Method of Disposal <br /> Distance to nearest: Well Oa7' Foundation _ _/O __ _ Property Line 1,A: <br /> LEACHING LINE EW No. & Length of lines 3-C, Total length/size ►fid'' (�� <br /> FILTER BED CI Distance to nearest: well.—/ Foundation Property Line <br /> SEEPAGE PITS lq­'�Depth srl -SizeNumber <br /> SUMPS LI Distance to nearest: Well IS©t Foundation_ .._ Q?` Property Line 10c;'- <br /> DISPOSAL <br /> Oo;'-DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt 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 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required insPections. Co plate drawing on/reevvers-,e side. <br /> Signed X—c Title: '^' Date: -�?-fZ <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 47 Area 2-- <br /> Pit or Grout Inspection by Date Final Inspection by Date { <br /> Additional Comments: <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 /> kFEE FB AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (� DATE PERMIT NO. <br /> EH1321 IREV.+i x SI <br /> EH 71-2e <br />