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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />' ENVIRONMENTAL HEALTH DIVISION ` <br /> 1601 E. HAZELTON AVE. , PHONE (209)488-3420 ,� 0��� <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PEUIT EXPIRES I YEAR FROM DATE ISSUED { <br /> l (Complete in Triplicate) r <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 Ln0e in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Countyis Health(8�ervices. <br /> Job Address City <br /> y 4�wot <br /> Size/Acreage <br /> Owner's Name _ !_ — V/4 YN7 w%ddress <br /> Phone i <br /> Kontract r —" Address L., r-or License No. Phone �. rr <br /> TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT,CI,-- y DESTRUCTION ❑ Out of Service WeIZ 1,0 <br /> - -- PUMP INSTALLATION..O,._,-•.__.- __ }� SYSTEM_FtEPAiR-❑ rr_ _ OTHER 0 Monitoring Well'' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMIls <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( I <br /> I <br /> f-1 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia.�ofxlNe�l Casing 4 <br /> I L." in.re�-��i 4 <br /> fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing 5 titications <br /> I'I Public I-) Other f n Delta Depth of Grout Seal <br /> } .Type Grout <br /> i <br /> I I Irrigation � .„�..Approx, Depth l I Eastern Surface Seal Inst ed bye`""-� � -. � a <br /> Repair Work Done U Type of Pump H.P. St ork Done r T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth ff Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 .REPAIR/ADDITION I I DESTR CTION o septic system rmitted if priblic sewer is . <br /> available within <br /> Installation will serve: Residence I� -Commercial Other l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth"�- <br /> SEPTIC TANK.- 0 Type/Mfg ? Capaciiy No. Compartments <br /> PKG. TREATMENT PLT. C7 Method of Disposal I <br /> a <br /> Distanceto nearest: Well Foundation Property Line f <br /> LEACHING LINE ❑ No. & Lerigth of lines Total length/sire <br /> FILTER BED Cl Distance,to nearest: Well r Foundation Property Line j <br /> � <br /> SEEPAGE PITS ( I Depth a Size ' ? I <br /> Number ; <br /> SUMPS LI Distance+to nearest: Well ` Foundation Property Lirie ' <br /> t <br /> DISPOSAL PONDS ❑ <br /> hereby certify that i have prepared this,application and that the work will ba done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 5 <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,&the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic tall for required inspections, Complete drawing on reverse side. <br /> i <br /> l R <br /> igned X_ Title: Date: 1[-:I I_ <br /> �EPARTMENT USE ONLY <br /> Application Accepted by Data <br /> Area <br /> I ZSRPit or Grout inspection by '� pate Final Inspection by Data <br /> Additional Comments: s <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, EnvirozeltonnAve., Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 2...� <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT,NO.. <br /> INFO ^ CASH <br /> . EH 13-24(REV.i i w sf 11 1 ( 7 ( � _ ) ] I/- <br /> �jq� <br />