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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 BOX 2009, STOCKTON, CA 95201 <br /> ESP RES 1 YEAR FROM DAT ED <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public H}e�alth Services. r <br /> Job Address SL 5 ,`r/ a ft City_�3 ��D10 Lot Size/Acreage <br /> Owner's Name �Ar D•�tit Lc+, I Address Phone <br /> Contractors gf..nM r{� Address License No. _&� a, Phone . 2 t741$ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR D 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 /> * industrial O Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private D Gravel Pack F7 Tracy Type of Casing Specifications \ <br /> I'1 Public 1-1 Other L1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ._.--..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material d Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I } DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence AL Commercial_ Other <br /> Number of living units: ,j, Number of bedrooms_3___ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. d Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal Q <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE ❑ No. F, Length of lines Total lengthtsize <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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 applicanust call for�l required inspections. Complete drawing on reverse side. t <br /> Signed Title: __ CAJ dater` <br /> FOR DEPARTMENT USE ONLY �y <br /> Application Accepted by Date ! �� Area <br /> Pit or Grout Inspection by Dateinal Inspection by '�"w''-�-_-`� Date <br /> Additional Comments: Z MnI/ <br /> Applicant - Return all copies to: San Joaquin County Pub is Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009,' Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'N0. <br /> + EH 13.24(REV. <br /> EH 14.25 ,v <br />