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I <br /> APPLICATION FOR PERMIT <br /> �� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> j ENVIR0NMENTAL HEALTH DIVISION <br /> 1-A 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERYIT 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 ty Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealthServices �r <br /> Job Address L 6 0 1 � CityCIt.^,Lt►ts Lot Size/Acreage <br /> Owner's Name Address Phone tlrt <br /> €� 31115's Phone'33 ` 71-S <br /> Contractor_ �t"f� C712d SS Address License f�Ea <br /> TYPE Of WELL/PUMP: _ NEW WELL $V WELL REPLACEMENT 1:1 DESTRUCTION Cl Out or Service Well 0 <br /> PUMP INSTALLATION : SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <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 /> C] Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing G <br /> ;;Domestic/Private 5h Gravel Pack ❑ Tracy Type of Casing to 10< Specifications ,F-YFD <br /> Cl Public CI Other n Delta Depth of Grout Seal O Type of Grout <<-rhL <br /> I I Irrigation 3 20—Approx. Depth Il Eastern Surface Seal Installed by C J A+��AC%�,( n <br /> Repair Work Done 0 Type of Pump V� H,P. State Work Done._0212 Te-e-LV <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.] <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK, O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total lengthlsize <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size.�� Number. <br /> SUMPS LI Distance to nearest:' Well Foundation- Prop_eriy Line <br /> DISPOSAL PONDS 0 <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 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 <br /> �must <br /> �call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: D°t,&� r.._._ _ Date: G <br /> F ARTMENT USE ONLY <br /> Application <br /> Accepted by Date in Area 2— <br /> Pit 0r/Gr9Gt Inspection b� Date Final Inspection by to <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 /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED 9Y DATE PERMIT NO. <br /> a EH 13-24(REV,I/n 5) WAN I�q .�o '"I •11�� 1-{`�`-� <br /> EH;426 w I 1 <br /> } A <br />