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APPLICATION FOR PERMIT <br /> 1 :�7C1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ' <br /> MMITE%P RES 1 YEAR FRQM DAT ED <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 CCwpliance 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 ;Z5707 E, LL 2,6 O <br /> (� r� City Lot Size/Acreage <br /> Owner's Name Rf W1(l` ( Address '7 Z m� <br /> r-- Phone <br /> Contractor Address G 2_8 1 C?'$t7 `}license No. �9�t57 Z;Phone 7 7i 9�7` <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK ��,,,,nn�� ❑ <br /> SEWER LINES -�� DISPOSAL FLD.'r" PROP. LINE `+t•�> <br /> FOUNDATION AGRICULTURE.WELL.== OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrialp [ (I <br /> 'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (i �! <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing <br /> i'i Public Specifications <br /> C7 Other n Delta Depth of Grout Seal <br /> Irrigation _50-0. of Grout <br /> i I lrriga <br /> _50-0.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H P <br /> State Work Done <br /> Well Destruction ❑ Wei I Diam w Sealing Mater Depth <br /> Dept Filler erial S Depth <br /> TYPE OF Sa EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Installation will serve: Residence— ommerciai____ Other available within 200 feet.) <br /> Number of living units: Number of be <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg apaciiy� No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> Method of Disposal <br /> f. Distance to nearest: W Foundation Property Line ' <br /> LEACHING LINE El No. & Length o es <br /> FILTER BED Total length/size <br /> L7 Distance t sorest: Well Foundation Property Line <br /> SEEPAGE PITS I I pth Size <br /> SUMPSNumber <br /> Distance to nearest: Welt Foundation <br /> DISPOSAL PONDS ❑ ------ Property Line <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county. <br /> rules and regulations of the San Joaquin County ordinances, state laws, ander <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, f 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 fotlowin "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 taws Of Cahfor a." <br /> The applicant m It to ired ins ons. Complete drawing on (eversp side, <br /> .r <br /> Signed X Title: f <br /> Date: {� <br /> TfAENT USE ONLY C. i V <br /> Application Accepted by DateI v <br /> Area <br /> Pit or Grout Inspection by <br /> Additional Comments: Final Inspection by Date Data -� <br /> 8 <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> M Services, Environmental Health Permit/Services / <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201- <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO [CASH RECEIVED BY DATE PERMiT'NO. <br /> r EH 2�IREV. /n 5i <br /> A, <br /> EH:x•26 (j r <br />