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7 <br /> 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 /> EXPIRES 1YEAR FROM DATE 15SUED <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 <br /> j Public Health Services. <br /> Job Addressa{ty3 I [} <br /> .z r City Lot Size/Acreage <br /> Owner's Name Aki-_�ce fo r Auc7 Address ` O I" PICK. 1Jk►4 S.A, Phone r <br /> �ContractorLlS6r�A��A[fCh�[JGCCtJdt�, Address . �3" R it"6 -� `"' " LicensP Phone-E <br /> TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monit o ring Well �� t <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 I PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f E � <br /> n industrial © Open Bottom + D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E Domestic/Private ❑ Gravel Pack C1 Tracy - Type of Casing Specifications <br /> Il Public FI Other ❑ Delta Depth of Grout Seal Type of Grout) <br /> I I Irdowion �.Approx. Depth 1 I Eastern Surface Sea[ Installed by 3 I <br /> Repair Work Done 0 Type of Pump H.P. State Work Dana <br /> Well Destruction ❑ Well Diameter ' Sealing Material & Depth ' <br /> Depth Filler Material & Depth + t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION i I lNo septic system permitted il.public sewer is <br /> available within 200 feeta ' <br /> Installation will serve: Residence tv_ Commercial — Other �� <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 Com � s~ Ca acityfLIDO '-""'NoCompartments x- <br /> V' <br /> PKG. TREATMENT PLT. C] r '' I Method.of?isposal <br /> Distance to nearest: Well Os + Foundation .U0 Property Liner �0-F <br /> LEACHING LINE jV No. & Length of lines Total length/size <br /> FILTER BED >, D Distance to nearest:. .,; Well"14b, Foundation IP r� Property line _ /D' <br /> SEEPAGE PITS Af Depth s Siie' """"� Number------ <br /> SUMPS .0, -Distance-to'nearest: Weil l� Foundation_ � ,y ,h Property Line lD 1-A-- lam. t <br /> DISPOSAL PONDS ❑ -4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws,.-and — <br /> rules and regulations of the San Joaquin County 1 11, , _ Q� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work-fo which this permit is issued, I shall not Il <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 /> The applicant must call for II required inspections. Complete drawing on reverse side. <br /> Signed Title: D` i+te: <br /> FOR DEP RTMENT USE ONLY <br /> Application Accepted by Date-3 !Ta Area <br /> P or Grout Inspection by Date Final Inspection by/l-e Date3�_ 6 <br /> (Additional Comments: <br /> Applicant - Return al1 copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO }.�AMOVNT DUE AMOUNT REMITTED CKSH RECEIVED BY DATE AERMIT'N0. <br /> a EM 13-2�[REV.t/n 51 ' I <br /> f� � , ` 1 v '� X�D 9�-t.� <br /> EH 14.20 1 v \ LJ <br />