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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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 /> Q► ,n <br /> Job Address � � �� �r !' ) ( ��a�� City ���_I� Lot Size/Acreage <br /> "q' /6O t 2- 13'1 C1 L IM" /9F, Phone S 7- <br /> / <br /> Owner's Name -Ter T r �J P e-&- Address f_0 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done U 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 ( REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if 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: 5 &_-t ID �a/}�v►e Water table depth <br /> SEPTIC TANK II✓Type/Mfg e✓e r� Capacity 17-OD No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal �J <br /> Distance to nearest: Well (0 U"Y Foundation 0 Property Line <br /> TID .5£r v,.P— X,4A-/,� , JS� r <br /> LEACHING LINE Cl/No. & Length of lines Total length/size <br /> � <br /> FILTER T Distance to nearest: Well Q� Foundation 0 Propert eine <br /> X, <br /> L4 S_ Z. R7' e —a c-l�-u �n ® e-.r ' Pe, <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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: "1 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 applica ed ' on omplete drawing on reverse side. Q q <br /> .Q ��' <br /> Signed Title: b a,� iR ►r Date: <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date / Area ` g <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date d <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. <br /> INFO CASH <br /> . EH 13-24 IREV.1/9 S) <br /> EH 71•Za ' /Z•. =j a . <br />