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V 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 /> REMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address .14 City C 6_ Q Lot 81ze/Acreage 2 <br /> Owner's Name tea,rD�M�-- Address _4 4 S 4r U -- Phone � <br /> Contractor_ til Su ! Address -e a o d Qi t0 License No. �S�Phone <br /> TYPE OF WELL/PUMP: 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 /> FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation, Dia. of Well Casing <br /> Domestic/Private kGravel Pack ❑ Tracy Type of Casing let Specifications <br /> I'1 Public Q Other fl Delta Depth of Grout Seal {)�� Type of Grout {� <br /> I I Irrigation / i�z./Approx. Depth I 1 Easter" ' e Sea] Installed by a <br /> Repair Work Done 0 Type of Pump -S off.P u ac � State Work Done �A5 <br /> Well Destruction ❑ Well Diameter Sealing Materi 1 6 Depth <br /> Depth Filler Material 3 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial_ Other _ <br /> Number of living units: Number of bedrooms ti ► <br /> Character of soil to a depth of 3 feet: T'—_- Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ; ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f .k Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C] Distance to nearest. Well Foundation Property line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Found•ation Property Line , <br /> i <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 t. <br /> Home owner or licensed agent's signature certifies the following: ".certify that in the performanceofthe 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 /> 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." 1 �_- <br /> The applica t call for all required ins ' Complete draw on reverse side. - , f d <br /> Lie. <br /> r Date: <br /> Signed f <br /> taR DEPARTMENT.-USE•ONLY. - - <br /> va <br /> Application Accepted by Date 5�� Area <br /> t <br /> s <br /> Pit �6u� spection b�` Date Final Inspectign1bv / Ome <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services 1 <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 J� <br /> J <br /> Y FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> ,LU f <br /> . EH 13-24IREV.iiK5s A� C C,.aY1_..� �I Pis <br /> EH 14.24 N tO� D�l J .L� <br />