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I ; <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> k 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> f P O BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES 1-YEAR FROM DATE IaaUED <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> t <br /> Job Address a 6! City s LOQ"hot Size/Acreage <br /> Owner's Name - , J,,e Address d VL phone <br /> Contractor ddress <br /> ieense No. y3(t39'L PhoneS4.3 / <br /> ' . TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER p 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 /> M Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I.1 Public I:7 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by �j) <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter" Sealing Material & Depth ("} <br /> t Depth Filler Material & Depth l/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION f I lNo septic system permitted if pub;suw,,rs <br /> } available within 200 leet.l <br /> b Installation will serve: Residence�t Commercial_ Other c r (� <br /> Number of Living units: � Number of bedrooms v/ f <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. C7 Method of Risposal <br /> Distance to nearest: Well tl�T _ Foundations ' Property Line <br /> LEACHING LINE LW'-No. & Length of lines -1" s `Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS E I Depth Size Mumber s <br /> SUMPS 4r- Distance to,nearest: Well�_ Foundation Pro <br /> party Line.�Q <br /> DISPOSAL PONDS Q � i <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 laws of California."Contractor's hiring or subcontracting signature <br /> certifies 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 la of alifornia." i <br /> The ap is .t.must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: �. tLk � p <br /> R DEPAR ENT USE ONLY <br /> Application Accepted by �Q <br /> Date Ar <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments; I {F` <br /> Applicant - Return all copies to: San J r <br /> oaquin County Public Health t <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t <br /> FEE. AMOUNT DUE AMOUNT REMITTED <br /> - INFO C RECEIVED BY OATS PERMIT'NO, H <br /> . EH -24 iREV.tIK6i <br /> EHA-25 i�•?8 t <br /> f <br />