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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 /> EXP RES 1 YEAR FROG DATE ED <br /> (Completer in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This I <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CounyPuublic Health Avicee.Job Address /Z/5,1 0 ��SQfOj�J� <br /> City Lot Size/Acreage D <br /> i <br /> ,/y� d <br /> Owner's Name 3. b� //lgC,,4A Do Addressl! /,�A!,A,_ Y1'�� Phone Tr 7 Z <br /> Contractorz4.z Gi iRo rs, Address License..No. tf Pho � <br /> TYPE OF WELL/PUMP: NEW WEL ,WELL REPLACEMENT ❑ DESTRUCTION 1 1 Out of Service Well ❑ <br /> 4 <br /> PUMP INSTAL-LATION>e SYSTEM'REPA"IR"❑ OTHER 0 Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /D SEWER LINES DISPOSAL FLp,A�-O_� -PROP. LINE Li— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia."of Well Excavation Dia. of Well Casing � <br /> Domestic/Private >6 Gravel Pack 0 Tracy Type of Casing Specifications.�� '' <br /> I 1 Public 1:1 Other fl Delta t, Depth of Grout Seal - 0 a Type of Grout Ct Ek C.If ? <br /> I I Irrigation Approx. DepthI Eastern: a '` Surface Seal Installed by a C 53 <br /> Repair Work Done [2 Type of Pump K H"P- ^f State Work pone _ <br /> Well Destruction ❑ Well Diameter Sealing Ma erial Depth <br /> Depth Fi11er')ateria7 &-Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I 1 <br /> DESTRUCTION I I (No septic system permitted it public sewer is € <br /> 1 41 <br /> available within 200 feet.) �l <br /> Installation will serve: Residence` Commercial— other, <br /> Number of living units: Number of bedrooms i _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. I <br /> ❑ Type/Mfg 'Capacity` No. Compartments " <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines r Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size - "Number ' <br /> SUMPS C3 Distance to nearest: Well Foundation L_ Property Line f <br /> DISPOSAL PONDS p <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 erriploy persona subject to workman's comjiensa- <br /> tion laws of California:" R ' <br /> The applicant must c9 for all requi d inspections. Complete drawing on reverse side. x <br /> Signed X_ —... Title: $tCa12!►+. <br /> •., _ „� Date: <br /> O RTMENT USE ONLY [� <br /> Application Accepted bAb <br /> Date L1—� i <br /> ea <br /> I <br /> Pit o Grou Inspection Date, Final Inspection b Dat <br /> Additional Comments:Applicant - ReturnSan J <br /> oaquin County Public Health //// <br /> Services, Environmental Health Permit/Services�Z,, <br /> 1601 H. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT OfJE AMOUNT REMITTED CK RECEIVED BY <br /> INFO +CASH OAATEg P/EiRMIT'NO. <br /> . EH 13-741AEV.iK513 �( 0-C> <br />