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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE.. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 9A 7V6 <br /> PERMIT EXPIRES_ 1Y_£_sAR FROM DATE ISSUED i <br /> f X03 Igo <br /> (Complete in Triplicate) j <br /> Application its hereby mad to S 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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. GFt�-Q�� t^p�..RlY tsuf3IJ f}p/V SOS--33—Z3 _-xc 11 <br /> ���� "IV 2-4 33 Zt -- ZO -- 84511) <br /> Job AddrtT% City a3 Y-Af_41 Lot Size7Acreage <br /> Owner's Name L G. Address y fl7ff 1tV16 —_n_1V,7rAh,ne <br /> Contractors c ss �� ter YnY � ense No. Phone gy�r�3y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ e <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP.-N#6r r�T <br /> FOUNDATION AGRICULTURE WELL OTHER WELL $GCB <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> I"I Public Cl Other n Delta Depth of Grout Seal <br /> 1 1 Irrigation —.Approx. Depth I I Eastern Surface Seai installed by W79Ti5I2 LIU— B k <br /> W Ir <br /> Repair Work Done 0 Type of Pump H.P. State Work Done ffiae PLjA6 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is Cy <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. ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ` <br /> Distance to nearest: Well Foundation Property Line 1 �' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED C:1 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS [ I Depth Size Number ,f <br /> SUMPS L! Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11 <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 milt call for all rad inspections. Complete drawing on reverse side. <br /> r / <br /> Signed X __ __._ Title: Date: <br /> ORD PARTMENT USE ONLY f/ <br /> Application Accepted by Date Area u <br /> Pit or Grout Inspection by Date Final Inspection b Datvo <br /> Additional Comments: <br /> Applicant - Return all copies to: Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0, <br /> INFO CASH <br /> . EH 13-24(REV.+/x sl <br /> EH 14.25 <br />