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't <br /> APPLICATION FOR PERMIT ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Ji <br /> ENVIRONMENTAL HEALTH DIVISION <br /> X601 p- O BOXL2009AZETON �,VSTOCKTON, CA 952013420 <br /> EXP RES 1 YEAR FROM DA F � <br />` (Complete in Triplicate) j <br /> work herin describe . Thi <br /> Application is hereby made,to San Joaquin <br /> Ban Count549 Ordinance nNo� and/or <br /> 549and1662sand thee <br /> cRules andeRegulationsdof Sans <br /> application is made in compliance <br /> Joaquin County Public Health Services. <br /> a�-�j�1 - � h City ^� o Lot Size/Acreage <br /> Job Address 1 Y ' <br /> QJ r Phone <br /> i "� Ra Q E Address <br /> Owner's Name -.�-��- <br /> IegdX10 CF License No. � � Phone <br /> Contractor 1°t { Address <br /> NEW WELL WELL REPLACEMENT D DESTRUCTION ❑ Out Monitoring Ke11�0 1` <br /> TYPE OF WELL/PUMP: -. ;.SYST_EM`REPAIR D OTHER C <br /> PUMP INSTALLATION (� <br /> SEWER-LINES ,� ----- - DISPOSAL-fLD:--- --PROP.-LINE �f✓ <br /> C DISTANCE TO NEAREST:-SEPTIC T.ANKY --AGRICULTURE WELL OTHER WELL PITSISUMPS _ y} <br /> ' FOUNDATION -- LXX <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> D Industrial C1 Open Bottom Manteca Dia,. of Well Excavation <br /> l Type of Casing- <br /> 1`7 <br /> asing � � Specifications <br /> f f 1 Domestic/Private Gravel Pack L7 Tracy Depth of Grout Seal + l� Type of Grout <br /> C1 Public I.1 Other' fl Delta <br /> I urface Seal Installed by <br /> I I Irrigation {�Approx. Depth l I Eastern <br /> k Repair Work Done Type of Pump H.P. <br /> f State Work Done <br /> Sealing•ldateriel & Depth ' <br /> Well Destruction 0 Well Diameter Filler Material & Depth D <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I <br /> availablewithin200 feetc systern r'jed if public sewer is <br /> 3 <br /> I Installation will serve: Residence— Commercial_ Other ! �-- <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> i Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. 0 Type/Mfg Capacity--- <br /> Method of Disposal <br /> r PKC.'TREATMENT PLT. Cl <br /> "r Distance to nearest: Well Foundation Property Line <br /> - - Total length/size <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED Distance to nearesi�, Well Foundation <br /> Property Line <br /> i' <br /> Number <br /> SEEPAGE PITS l I ' Depth Size <br /> SUMPS LI Distance to nearest: Well -� --' Foundation Property Line <br /> DISPOSAL PONDS O <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-thabin the performance of the work for which this permit is issued, I shall not <br /> r 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 cerilfy that in the performance of the work for whic <br /> h this permit is issued;I shall employ person's subject to workman's compensa- <br /> tion laws of California." <br /> The applicant -Cst call for ail required inspec ions. Complete drping on reverse side. r YF - <br /> � <br /> Title: <br /> Signed XDate: <br /> FO DEPARTMENT USE ONLY �] <br /> Date ✓ rea a <br /> Application Accepted by <br /> Pit ocoui <br /> inspection bDate Final lnsp ction by Date <br /> Addiomments: <br /> Applicant - Return all les to: San Joaquin County Pub l c th <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave„ P 0 Box 2D09, Stockton, CA 95201 w <br /> FEE CK RECEIVED BV �[jDATE PERMIT NO. <br /> INFO AMOUNT DtJE AMOUNT REMITTED CASN <br /> . EHU-24[PEV.Fn5) <br /> t6H 1426 .,� - <br />