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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)46$-3920 �' �' <br /> P O BOX 2009, STOCKTON, CA 95201 � � <br /> kMIT EXPIRES 1 YEAR F%LM DATE ISSUED S ASS? <br /> (Complete in Triplicate) <br /> �,���Q S'✓F�� vv SGP] <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work�h r�nmd�e6crd"V `Phis <br /> application is made in cotspliance with San Joaquin County Ord nance No. 549 and 1862 and the Rulee� 'a e&i`ati'ons of San <br /> Joaquin County Public Health Services. <br /> �a fes' G�yVI�' <br /> Job Address _ 2 � �L'P/' e City aG10 Lot Size/Acreage <br /> Owner'a Name, ejec �f'71141 t't' Address s ,a,Ae_ _ !e/ffrle 4,f- Phone <br /> Contractor of S -�/`I�. Address ��� License No.3`/57�' Phone " 3 "s6 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INST41-AtION'9 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Botiom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public la Other n Delta Depth of Grout Seal Type of Grout <br /> I I irrigation "_Approx. Depth LI I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump , 1:::A <br /> H.P, s State Work Done it <br /> Well Destruction ❑ Well Diameter Seallgg Material k Depth <br /> Depth Filler Material ri Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION [ I DESTRUCTION [ I iNo septic system permitted if public sewer is <br /> available within 200 feet.) �- <br /> Installation will serve:- Residence J Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of$ fest: Water table depth <br /> `SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> n <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth f Size Numbar - <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ Q <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, 1 shall not 1� <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's(tiring or subcontracting signaturef� <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." T <br /> The applicant us t all f�rI-- <br /> 11 requ' 'i Ctions. Complete drawing on reverse side. <br /> Signed Title: �Lrf�� G A d �" Date: <br /> ✓� <br /> DEPANT <br /> Application Accepted by Date �Z rea � <br /> Pit or Grout Inspection by Date Final Inspection b Datta <br /> Additional Comments: <br /> Applicant - Return all copies to:i San Joaquin County public Health <br /> ! , <br /> services, knvirotsmental Health Permit/Services <br /> k1601 E• Hazelton Ave., .P. 0 2009,_Stockton,_CA._95201FEE <br /> INF AMOUNT DUE MOUNT REMITTED C K ECEIVED BY ATE PERMIT NO. <br /> — W <br /> . EH 13-14 SREV.1/H 5) fr f off <br /> EH t4-2a <br />