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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICTsS � Q <br /> ENVIRONMENTAL HEALTH DIVISION <br /> a17 � 1601 E.. HAZELTON AVE. , PHONE (209)468-3420 <br /> � r P O BOX 2009, STOCKTON, CA 95201 SCANNED ; <br /> EXPIRES 1 YEAR FROM DATE ISSUED . <br /> (Complete in Triplicate) <br /> Application is hereby reads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cortrpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Josquia County Public Health Services. t �✓�77a3D-13 <br /> V Job Address ° Lot Size/Acreage �0 <br /> A_ # � F/lE"`Nd �• Phone �9 �" Z�,63 <br /> Owner's Name TTC �ew4nnX A4L,Address �� � S# <br /> Address License No. ��� Phone N/A <br /> ontractar <br /> Out of Service Well _❑ <br /> REPLACEMENT ❑ DESTRUCTION ❑ �. <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL a <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 7+ I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA"'CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. o!Well Casing . <br /> {_3 DomesticlPrjVate. ❑ Specifications <br /> Pack ❑ Tracy Type of Casing d <br /> ['i Public Ia Other C-1 Delta Depth of Grout Seal Type of Grout <br /> I I lrrigation _Approx. Depth l 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 l REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms A/ <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 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 11 <br /> .FILTER BED ❑ Distance to nearest: Well Foundation Property Line + <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 mus tali for all required ins ctions. Complete drawing on reverse side. <br /> Signed Tills: 1'I&- ,E- — Dater <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date 1/� � Cj Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> t Additional Comments: <br /> 4:Gir-r�J ����- <br /> i <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental health Permit/Services <br /> 1601 E. Hatelton Ave., P 0 Sox 2009, Stockton, CA 95201 <br /> FEENT DUE AMOUNT REMITTED CK RECEIVED BY DA PERMIT NO. <br /> ` INFO � CASH �y <br /> l r EH 13.24 IREV.1/n51 �r� ��-rr ! Fo—A� <br /> EH 14.26 <br />