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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 /> EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby Stade 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 1$62 and -the Rules and Regulations of San' <br /> Joaquin County Public Health Services. /�1 ��{y'� <br /> Job Address <br /> l City s caz2 +�'ot size/Acreage <br /> Owner's Name R C) <br /> Z Address �'� j� Sca4,17& (If-� Phone <br /> 3 l <br /> Contraclor Address License N Phone k <br /> TYPE OF W LL/PUMP: NEW WELL D WELL REPLACE NT 171 DESTRUCTION ❑ Out of Service Well <br /> LI <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O <br /> l DamesticlP�ivate 1=1 Gravel Pack Ll Tracy Type of Casing Specifications 1 3 <br /> �` Type of Grout <br /> I'1 Public ,. 1 OI-],Other-. �' fl Delta Depth of Grout Seal I <br /> I I Irrioation ' 4 —.Approx. Depth I i Eastern Surface Seai installed try <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> 'DepthFiller Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INos ptic system <br /> rmit`ed if public sewer isavaila <br /> Installation will serve: Residence _-. Commercial Other ' <br /> Number of living units: J..._ Number of bedroom, O <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> — c -_ <br /> SEPTIC TANK ❑ Type/ f _ /C�ap�a6ty I No. Compartments <br /> PKG. TREATMENT PLT. C1 / 1•� `� f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> SEEPAGE PITS Depth Size Q Number <br /> SUMPS Distance to nearest: W i Foundation-1466 Property Lint <br /> DISPOSAL PONDS 0 <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 workmen's compensation taws 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for a in ctions. Complete drawing on reverse side. ) <br /> Signed "^� Title: Date: W`FOR D ART E-ONLY <br /> Application Accepted by Date Area <br /> Pi jor Grout Inspection by Date Final Inspection by � 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO !•^/ <br /> . EN 13-24(REV.��HSI 1 � -"i <br /> EH 14-26 <br />