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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <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 IS9VED <br /> (Complete in Triplicate) <br /> Application is hereby madetoSan Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules end Regulations of San <br /> Joaquin County Public Health Services. <br /> F - � �4 <br /> Job Address _ 'F i S� ---- City i RF 4.� Lot Size/Acreage <br /> 19 <br /> Owner's Name p� AddressPhone <br /> Contractor 64 IN .3 GtAddiessA&Q 6OX �& �Ab License No., t.2 ` 1 Phone <br /> TYPE OF WELT./PUMP: I NEW WELL-❑, �._ _.;_WELL REPLACEMENT ❑ __DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> J <br /> F06NDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS <br /> INTENDED USE TYpE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> r <br /> Cl Industrial C1Open Bottom ❑ Manteca Dia. of Well Excavation ' '� Dia.:of Well Casing <br /> C1 Domestic/Private Cl Gravel Pack E3Tracy Type of Casing 4. Specifications <br /> {'1 Public to 0'1 her n Delta Depth of Grout Seal ` -i'- .."Type of Grout <br /> h <br /> t I Ifrigation —!Approx, Depth I I Eastern Surface Seal Installed by - t <br /> Repair Work Done 0 Type of Pump H.P,' "'`.State,Wo'rk Done_ <br /> ' <br /> Well Destruction Cl p Well Sealing Material & Depth <br /> Diameter <br /> i` Depth Filler Material & pepth <br /> V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: r Residence Commercial'"Other 1 <br /> Number of living units: _.G '! Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> "SEPTIC TANK. -0 Type/Mfg - - - Capacity'--. No:-. No: <br /> PKG.KG. TREATMENT PLT ❑ ,I� Method of Disposal <br /> Distance to nearest: Well ' Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: (Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth f r _Size 7i r _ Number ! ' <br /> SUMPS Distance to nearest: Well Foundation' Z-6 Property Line i/D f C <br /> DISPOSAL PONDS ❑ <br /> 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 workmen'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 employ persons subject to workman's compensa- <br /> tion laws of California." t <br /> ! --��„ - - <br /> The applicant m call for all rJeql"red inspections. Complete drawing own reverse side:'°"'—' p <br /> II Signed t{ Title: Date: 6'21 <br /> j� <br /> FORDEPARTMENT USE ONLY <br /> I <br /> Application Accepted by IM Date i` Area L _ <br /> Pit or Grout Inspection by I� Date Final Inspection by / Data <br /> Additional Comments: <br /> x- Applicant - Return all copies to: San Joaquin County Publle Health <br /> a. Services, Environmental Health-Permit/Services <br /> i <br /> j 1601 E. Hazelton Ave..--P d'Box 2009; "Stockton, CA- 95201FEE ` <br /> 1 INFO AMOUNT DUE AMOUNT REMITTED CASH CK A <br /> RECEIVED BY DATE PERMIT'NO <br /> f111 ♦ EH 13-24(REV.i M 51 � <br /> EH 14.20 <br /> I I� <br />