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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY,PUBLIC HEALTH SERVICES <br /> ' � ENVI-RdO ENTAL�,HEALTH DIVISION <br /> 1601 E. HAZELTON AVE.`, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED , <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Address :3L/S-0 Cit Lot Size/Acreage <br /> AAk <br /> JA41'es 61MAAddress `�T a 7 &C f Phone � yOwner's NameI <br /> �7 <br /> Contractor �_l " AddressPO <br /> License No. �" Phone= <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION 9�-' SYSTEM REPAIR ❑ 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 /> C1 �Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (015cmestic/Private 0 Gravel Pack C Tracy Type of Casing Specifications <br /> I'l Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> I } Irrigation ./ Approx. Dept I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Lk Type of Pump H.P. State Work pone <br /> dol <br /> Walt Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth ; Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth C) <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 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS > LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ " <br /> I hereby certify that 1 have preparetl 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 r <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 pe 2su anner as to become subject toworkman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the flowify that in the pert ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion laws CalifThe appO ant ll q Ions. C yawing on r side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY C� <br /> Application Accepted by Date ` Area <br /> If Pit or Grout Inspection by Date Final tnspectlon by Data <br /> Additional Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health <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 RECEIVED BY DATE PERMIT'NO. <br /> INFO L�// /�``�� CASH ��}{-�, q <br />{ . EH 1924 1AEV.i/A51 -05•t3o5. V V 'U—� 7 C� O <br /> 1 EH A-26 ii <br />