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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 BOR 2009, STOCKTON, CA 95201 <br /> RERMIX 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealthServices. <br /> Job Address 2,Vati City K�DJ Lot Size/Acreage <br /> Q . <br /> Owner's Name Address Phone 9.1 7 -z 9 <br /> Contractor4",, LILL ffRole,4 Address � ?i y3 ��,7Zi C __ ._ License No.AY12110 Phone 4p'��Z ?Q S <br /> TYPE OF WELLIPUMP: NEW WELL-0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATiON E3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK = '"y SEWER LINES 'DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 4 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 /> [1 Domestic/Private ❑ Gravel Pack rL1 Tracy Type of Casing Specifications ww. <br /> i'l Public [a Other "� R Delta ; Depth of Grout Seal Type of Grout <br /> I I Irrigation .rt.,,-Approx. Depth 11 Eastern Surface Seal Installed by s <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth 1 <br /> Depth Filler Material'& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> t ' available within 200 feet.) <br /> r <br /> Installation will serve: Residence "" Commercial�J Other" """"""—' <br /> Number of living units: l Number of bedrooms 7 ,t y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK d Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Y- a. F.. _ "� ,. �� d_ 4,Method of Disposal <br /> Distance to nearest:- Well -Foundation 'Propertj Line <br /> LEACHING LINE 1' No. & Length,of lines ,,, f� a Total length/size <br /> FILTER BED CI Distance to nearest: Wel &me Foundation /b� Property Line �� + <br /> SEEPAGE PITS De th a } Size- Q f - V <br /> I' p Number <br /> SUMPS Ll Distance to nearest: ,Well /eaZt Foundation"'la z� 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, ` ` I <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 /> r 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 /> The applicant must call for all required inspections. Complete drawing on reverse side <br /> Signed -Title.� A ' _ Data. 'T' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date (� 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by y- Date <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED 13Y DATE PERMIT NQ. <br /> + EH 13-24 4AEV.1/,4 51 <br /> EH;4.28 -^- / D <br />