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' APPLICATION FOR PERMIT <br /> � v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE: , PHONE (209)46$-3420 <br /> r P O BOX 2009, STOCKTON', CA 95201 <br /> EXPIRES 1 YEAR FROM-DATE ISSUED s <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 77 <:�O PS �� City Lot Size/Acreage A CyeS <br /> /�d✓yx L JoO`�¢✓Gt�+'t Address 7 Z ` <br /> Owner's Name � <br /> ontractor <br /> C3L�J /Z ✓' Address �7 So`l�s License No. Phone 3E,�'X70 <br /> PE OF WELLIPUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTIONOut 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [:7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> ['I Public [-I Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br />` Depth Filler Material & Depth t . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is N <br /> available within 200 feet.) 1 <br /> Installation will serve: Residence— Commercial— Other <br /> I <br /> Number of living units: - Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LD No. & Length of lines Total length/size _ <br /> FILTER BED L'3 Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS II Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation . _ Property Line <br /> DISPOSAL PONDS ❑ <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 workman's compensation taws of California."Contractor's hiring or subcontracting 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 mus all for all requi d inspections. Complete drawing on revs side. <br /> Signed X Title: .__. ' Date: <br /> HENT USE ONLY <br /> F Application Accepted by Date Area <br /> I <br /> I Pit or Grout Inspection by Date Final Inspection by S �t� Date <br /> Additional Comments; <br /> Applicant - Return all copies tor San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFE OUNT DUE OUNT REMITTED CASH CKI f , RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-24 011v.I I K 5) <br /> EH 3-2a <br />