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I APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> tl 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> # P O BOX 2009, STOCKTON, CA 95201 <br /> i PC, �, (/ RM12 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 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City L -Lot Size/Acreage <br /> i <br /> i Owner's Names Address _. _ .5C`l Phone <br /> COntracttSr Y Address -IjC;—;40A License No. d Phonef7/` <br /> TYPE OF WELL/PUMP: NEW WELL 0 � WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR Pe- 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 SPECIFICA�IIONS <br /> ` n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Orpomestic/Private. ❑ Gravel Pack L3 Tracy Type of Casing I Specifications <br /> Il Public (_1 Other F-1 Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrioation —.Approx. Depth 1 Eastern Sp ca Seal Installed by 42 <br /> [ Repair Work Done [ Type of Pump� H.P.. I State Work Dona <br /> Well Destruction ❑ Well Diameter w ,Sealing Material & Depth <br /> Depth Fi11er Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other t <br /> Number of living units: Number of bedrooms 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, D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest" Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth *- Size I Number <br /> SUMPS LI Distance to nearest: . Well - l71 Foundation Property Line <br /> DISPOSAL-PONDS- r D ./l, <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 orthe 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 the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject towork /�7 <br /> nsa- <br /> tion laws o ornia.." i. �' +a i <br /> The Itcant m t call for-all r d ins ons. Complete drawing on rev side. <br /> Signed ''t Title: {� Data: <br /> DEPART T-USI,: ONLY <br /> Application Accepted by _ Date 1Y'�Lam{; 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date6^ <br /> s Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ,moi V <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2069, Stockton, CA 95201 <br /> CK <br /> EH 13-24 TREY.i i a 51 K <br /> INFO AMOUNT DtjE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT N0. <br /> + EH 14.I6 S 1 L �Q.' I ' `�• 1,�_����GJ <br /> L <br />