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A APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> rt EN'V I RONMENTAij~,HEALTH DIVISION <br /> } r 1601 E. HAZELTON °AVE: , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> PFJMIT 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 compliancel with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> %17 'i >✓, , t�Ve CityC�+�j-� �r_j`_,_, <br /> Job Address _ r5 1c7'fZ ,�C�C.K di& Lot Size/Acreage <br /> ri <br /> Owner's NameIb l Address •PP— Phone <br /> �1 <br /> Contractor T `�'"" ' - `S Address L-C P O� Z- l License NoI7-31 Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL pEP,LACEMENT am,�g-�DESTRUCTIO Out of Service Well <br /> PUMP INSTALLATION f!-- / Monitoring Well <br /> Y SYSTEM REPAIR C] OTHER 0 �,. f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE '`_ ; <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t � -1tI. <br /> n industrial 0 Open Bottgm 0 Manteca Dia- of Well Excavation Dia. of Well Casing <br /> R Domestic/Private &Gravel Pack ❑ Tracy Type of_Casing__ Il G 5pecifications� ` <br /> I'i Public 1-1.Othar Cl Delta Depth of Grout Seal 0 Qr T pe of Grout <br /> I i Irrigation ¥Approx..Depth I I astern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. 4 { State Wor Dore <br /> Well Destruction 9' Well Diameter 42.11Sealing Material & Depth ' <br /> Depths Filler Mate' <br /> Depth i Depth+ <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is ' <br /> V available within 200 feet.) ' <br /> 1 , k <br /> Installation will serve: Residence= �. <br /> Commercial Other- <br /> Number of living units: Number of bedrooms <br /> ' Character of soil to a depth of 3 feet:t °= = t Water table depth <br /> SEPTIC TANK ❑A Type/Mfg P} Capacity,""" <br /> apacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ; Method of Disposal <br /> € Distance to nearest: Well Foun/dn/— Property Lina <br /> E <br /> LEACHING UNE Ll No. & Length of lines ?= Tota! length/size 'r <br /> FILTER BED C) Distance,to nearest: Well t Foun tion'" Property Line <br /> SEEPAGE PITS .I 1 Depth Size r Number <br /> M - s <br /> SUPS LI Distance to nearest: Wel Foundation,N_ — Property Line <br /> DISPOSAL PONDS 0 <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 Ii ant's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not <br /> i__ E of'Cdlif rrii' ""Contractor's hiring or sub-contracting signature <br /> employ any on in such manner as to become su ject to work`men`s-compensat on aws o g 9 9 <br /> card}las th ollowinp: "I c 'fy that i th o a e of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f California." " <br /> The,appl ant s I'or all rC,QrrrRtB>a drawing of v side. G, <br /> signed Title;_ Date: <br /> _ ,-. — - <br /> FO EPAR T USE ONLY <br /> i tion Acce ted b Date Area <br /> Appl ca P Y _ . ... ... _ ._ <br /> Pit or Grout Inspection by f' 4 y Date M Final inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health `jl3 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED BY DATE PERMIT'NO, <br /> INNF.Ot CASH <br /> + EK 13-21(REV <br /> EH 13-2e .1/n 5! :e�tA ` , � <br /> Yt�► 1�i� <br />