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F _+� APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> k <br /> ENVIRONMENTAL1601 E. HAZELAVE. , PHONE (209)468_3420 <br /> k P O BOX 2009, STOCKTON, CA 95201 j U-f'"' �/� <br /> PERMIT E%P RES 1 YEAR FROM DATE ffi) ---r�-f / r <br /> (Complete in Triplicate) <br /> t Application is hereby made to San Joaquin County for a permit to construct and/o`r''ingtall the work herein described. This <br /> application is made in compliance ,with San Joaquin County Ordinance No. 51+9 and 1862 and.the Rules and Regulations of San y <br /> Joaquin,County Public Health Services. ,, <br /> City ` 't <br /> � <br /> +� ��� Lot Size/Acreage ^ <br /> I -J6b Address Y <br /> Owner's Name <br /> J �'fc✓Adclress 1- f L i 7 Phone ' r <br /> Contractor <br /> lge frl r Address y� License No k Lg 7-� Phone �' y <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well <br /> ¢ PUMP INSTALLATION 17 SYSTEM REPAIR 0,. OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F Rj <br /> f C] Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> [}-Domestic/Private Ll Gravel Pack 0 Tracy Type of"Casing Specifications <br /> I'1 Public f-1 Other fl Delta Depth of Grout Seal f Type of Grout <br /> .. <br /> 11 IrrivationApprax. Dep h I I Eastern' S rfaee Seal Installed by <br /> - , <br /> Repair Work Done 0, Typ of-Pump H.P. State Work Done <br /> Sealing-Material & Depth <br /> Well Destruction 0 Well Diameter- i <br /> Depth Filler Material & Depth" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION i I (No septic system permitted if public sewer i <br /> •+ + available within 200 feet.l r- <br /> installation will.serve: Residence— Commercial_ Other <br /> f Number of living,units. � Number of bedrooms <br /> tr T Gftaracter of soil to a depth of 3 feet: Water table depth <br /> r SEP-TIC TANK. 0 Type/mfg,— Capacity No Compartments r 1 <br /> If PKG. TREATMENT PLT. ❑ ° r� E. 4 Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE El No,S Length of lines Total•length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> ISEEPAGE PITS 11 Depi h Size Number <br /> SUMPSLI Dist nee to nearest: Well Foundation Property Line <br /> N. <br /> DISPOSAL PONDS a 1 <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state la s, e. <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 rc; <br /> L 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 <br /> compensa-tion laws of California." F <br /> t <br /> i' The applicant ust all for all ..squired inspections. Complete drawing opo verse side. <br /> Signed X Title: /L� Date: <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by " _ Date ` Area <br /> ` Pit or Grout Inspection by Date Final Inspection by-:�� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health �- <br /> Services, ftvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> f <br /> I FE'E AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO. CASH <br /> .• £N 13-24 tREV.t/n 5) <br /> .tea <br />