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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> l 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> AlP O BOX 2009, STOCKTON, CA 95201 <br /> PER <br /> MIT EXPIRES 1 YEAR FROM DATE ISSUED <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 _F�5 r) CityST�`-'�-/ter` Lot Size/Acreage Y <br /> Owner's Name �'T ��J�K Address S/� �l G Phone C3 <br /> 3 <br /> Contractor C/ ����_ Address /�� License NoV. 3PE Phone33Y � <br /> TYPE OF WELL/PUMP:. NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONX Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK /l$ SEWER LINES DISPOSAL FLDPROP. LINE •ZO <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS j�p� N(,_1J0 <br /> C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing { <br /> ZUomestic/Private X Gravel Pack El Tracy Type a Casing �VC / Specifications pv <br /> I'I Public I-) Other n Delta Depth of Grout Seal Type of Grout <br /> I I IrrigationApprox..Depth f I Eastern ,Surface Seai Installed by <br /> Repair Work Done ❑ Type of Pump 5+�1�^ H.P. 1L„ r State Work Dane t�'JC�t.+�� �1 <br /> Well Destruction .'@' Well Diameter Sealing-Mat6kiiII& Depth <br /> Depth /: "Firer Material &`Depth f <br /> - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR <br /> IR/ADDITION 1 .1 `DESTRUCTION f I (No septic system permitted if public sewer is <br /> { available within 200 feet.) <br /> Installation will serve: Residence Commercially--Other I <br /> Number of living units:r ­*`.Number of bedrooms <br /> Character of soil'to a depth.00--feet:. Water table depth <br /> SEPTIC TANK ❑ -'Type/Mfg 'Capacity r. Na. Compartments <br /> PKG. TREATMENT PL-T�❑- ---------�* ' Method at Disposal i <br /> Distance to nearest: Well Foundation f Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well a � Foundation` -Property Line <br /> A � , <br /> SEEPAGE PITS I ) - Depth S Size Number ( n <br /> SUMPS LI Distance to nearest: Well Foundation Property Line lam' <br /> DISPOSAL PONDS ❑ s <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 i 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 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." <br /> t <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> wM ' <br /> NT US W f <br /> fiE ONLY q c <br /> Application Accepted by r Date 1 l�- Area 1 <br /> Pit o Gro Inspection Date��/ Final Inspectio by ��al �p tail <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies o:, San J in County Public Health "r <br /> Services, l;Yivironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> # <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMIT•NO,, <br /> . EK 17-21 IREV,t In 5! k�� <br /> EH s4.2e ^ j� <br />