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APPLICATION FOR PERMIT ^ 00 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> i P 0 BOX 2009, STOCKTON, CA 95201 <br /> EBMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County fors permit to construct and/or install the work herein described. This <br /> application is made in conpllance with San Joaquin County Ordinance No. 549 and 1862 and the Pules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address S 97�j City Lot Size/Acreage <br /> Owner's Name �' ddressL� J+ r�.a'ii t�{ 1 <br /> Phone <br /> Contractor Jx ess License No. J �/ �dPhone 7 p <br /> TYPE OF WELL/PUMP: NEW WELL 0W ELL REP 1 'CEMENT CJ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SY EM REPAIR ❑ OTHER ❑ i Monitoring Well L7 <br /> DISTANCE TO NEAREST'SEPTIC'TANK'""'4 SE R LINES ti* ' DISPOSAL FLD, PROP. LINE <br /> J FOUNDATION AGRI ULT E WELL ., ' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL # PROBLEM AR A CONSTRUCTION SPECIFICATIONS , <br /> Cl Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing- ±•. I ' <br /> 17 Domestic/Private. � .❑-Gravel_P_ack 0 Tracy Type of Casing 5pecifications� " `J i <br /> 1'i Public Cl Other n Delta Depth of Grout Seal Type of Grout } ° <br /> + I Irrigation Approx. Depth 1 I Easter Surface Seal Installed by , 1 <br /> Repair Work Donee ❑ 7ypa,of,Pump � H.P. State Work Doris, 1 r <br /> Well Destruction ❑ Well Diameter t„.l,t-- Seali Material & Depth i' € <br /> Depth FTller terial & Depth -�' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO I REPAIR/ADDITION } DESTRUCTION I I (No septic system permitted if public sewer is <br /> t;rl ti t av ilable within 200 feet.) <br /> Installation will serve: Residence v Commercial' Other, <br /> Number of living units:T Number of bedrooms V I= � <br /> /� ra t+�r <br /> Character of soil to a depth of'3 feet: A r� yyater taf�le epth <br /> SEPTIC TANK �p Type/Mfg Capacity - w a No. Compartmentsy"� '��` <br /> PKG. TREATMENT PLT. Cl` � Method of Disposal <br /> t'4 <br /> Distance to nearest: Well ounda[ion A Property Line20 _O <br /> LEACHING LINE ❑ No/& Length of lines <br /> T <br /> ' talsleng[h/size <br /> FILTER BED ❑' Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth r Size <br /> Number <br /> SUMPS Ul Distance to nears t: Well J_aL>_-- Foundation s Y <br /> Propefty Line -- <br /> DISPOSAL PONDS ❑ -- �1 <br /> I hereby certify that I have Oapared this application and that the work-,will,bedorie in accordance with San.Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County wT�` J %i (� <br /> Home owner or licensed agent's s'ighature certifies the following: "I certify that in the pr <br /> employ erforms ce of the work for which this permit is issued, I shall not i <br /> P Y any person in such manner as to become subject to workman's compensation taws of.Cslifornia.: 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 em � <br /> tion laws of California." p toy persons subject to workman's compensa• <br /> The applican ust call for squired ' speetions. Complete drawing on reverse side. Z � <br /> y , <br /> Signed X <br /> Title: :.. „.Para: <br /> FOR DEPARTMENT USE ONLY,,, <br /> lication Accepted by Date - Area <br /> /Opi Grout Inspection Date � Final Inspection`b 'Date � f <br /> Additional Comments: e <br /> Applicant - Return all copies to: San Joaquin County Public Health-;;' r r y <br /> Services, Environmental Health Permit/Services t <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ` <br /> FEE DU NT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. t <br /> r <br /> EH 14-241AEV. <br /> EH 4. <br /> aY i <br />