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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 /> PERMIT 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 compliance with San Joaquin County Ordinance No. 51+9 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 0&:�A City Lot Size/Acreage" /V / <br /> Owner's Name Address S ,,�� <br /> tr <br /> IY�ane <br /> r <br /> Contract Address {! License No.,VZ74 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n- DESTRUCTION ❑ Out of Service welt ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> •---DISTANCEOTO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELT 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 l <br /> Cii DomesticlPrivate ' HCl Gravel Pack L1 Tracy Type of Casing Specifications <br /> I'I Public *; F1 Other i-I Delta Depth of Grout SealType of Grout O <br /> Irrigations, ..Approx. Depth [ I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter , } " FSealing Material & Depth (v <br /> Depth Filler Material & Depth 4 j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I INo•se tics stem permitted if <br /> P Y p public sewer 7s <br /> available-withi 200 feet.) <br /> Installation wrill,serve: Residence Commercial_ _ Cher ; <br /> Number of living units: —L Number_ be roo`s <br /> Character of soil to a depth of 3 feel: FWater table depth + <br /> SEPTIC TANK` Type/Mfg Capacity' No.:Compartments <br /> PKG, TREATMENT PLT. , r—a - - _ Y <br /> �;-- !" _ y %, "Method of CDispotsal �. <br /> Distance to nearest: Well 5�' Foundation V .Property Line <br /> LEACHING LINE' N o. & Length of lines f l Total-Iength/size Q X <br /> FILTER BED Distance to nearest: Well_16—W Foundation} Property Lime <br /> -t.< .,r y-moi_j)_� . ', Ir"! j1. y� <br /> f - <br /> SEEPAGE PITS,— Depth M Number '� <br /> SUMPS atio <br /> _ Ll Distance to nearest: Well Found <br /> Size .- l� � <br /> W'���,{�„4� Property Line �'� •1,� - � '+ <br /> DISPOSAL PaNDS CI <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 subcontracting 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 /> s - <br /> The applicant ust call f re ifed inspections. Complete drawing on reverse <br /> �sid)e. <br /> Signed Title: V t - <br /> . - Date: : <br /> E FDEPARTMENT USE ONLY /�`/ <br /> Application Accepted by - Date ��6L " � z <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Datr <br /> Additional Comments: f, <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> t Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F O Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH <br /> r EH11.20 341 IREV,t n sl �, <br /> FH 7 r' / 4 p <br />