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r <br /> i APPLICATION FOR PERMIT <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE Igt5lEII <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 Public HeAlth Services. <br /> Job Address `✓`' 3 f City G 6 t /1 Lot Size/Acreage <br /> Owner's Name e,`� T Address �� '� Phone <br /> Address l rS License t�o. �Phone <br /> 'TYPE OF-WELL/PUMP: � �� NEW WELL❑" WELL'REPLACEMENT ❑v - DESTRUCTION ❑ Out of-3er•vice Well -0-1` <br /> ` PUMP INSTALLATION ❑ , _ SYSTEM REPAIR 0 OTHER C] Monitoring Well ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k1 <br /> F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> 11 Industrial f 0 Apen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1 C1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout <br /> 1 i I Irrigation ..Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wt ll Diameter Sealing Material Depth <br /> i ' Depth Filler Material !;s Depth <br /> 17 <br /> 11 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION DESTRUCTION I I INd septic system permitted if public sewer is <br /> available within 200 feet.) F- <br /> ., <br /> Installation will serve: Reis ydeni:e_"�--Commercia!'""'�" Other <br /> Number of living units: [.I Number of bedrooms <br /> Character of soil to a deptl; of 3 feet: �`"t - Water table depth <br /> p <br /> s <br /> i SEPTIC TANK I�Tye/Mig LO cfrZfi2. Capacity 1�'7��`'` - No. Compartments <br /> PKG. TREATMENT PLT. ❑ !; —.- t Method of Disposal <br /> Distance to nearest: Well ��,� Foundation Property Line <br /> LEACHING LINE No. & Length of.lines _ Total Is ngthlsize <br /> r S <br /> I FILTER SED C:3 i Distance to nearesir_ Weil�' Foundation ;Property Line 7 <br /> k SEEPAGE PITS Depth Size V Numbet 7:3 <br /> SUMPS LI Distance to nearest: Well Foundation _ Property Line _ <br /> DISPOSAL PONDS -p� <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 /> 1 rules and regulations of the San Joaquin'County t 'l <br /> i Home owner or licensed agent's signature certifies the following::"I'cartify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such rn8�finer'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 perm_it is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." II`, <br /> I The applicant must call for all!re 'red insPections. Complete drawing on reverse side.' s <br /> Signed X_��1[[ I � <br /> Title: �.tl�✓1 � Date: <br /> i i fJaw <br /> F, R DEPARTMENT USE ONLY <br /> Application Accepted by .Date Area <br /> i Pit or Grout Inspection by I�i Date Final Inspection by`' Date �� O <br /> t .Additional Comments: <br /> J� <br /> Applicant - Return all cl�pies to: San Joaquin County Public Health <br /> I Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton`Ave., P 0 Box 2009, Stockton, CA -95201FEE � r' <br /> h - <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> i ) <br /> ♦ EH 13-24 EH 4,26(REV.1 n t51 r/ om q� �� -1 3 v`O <br />