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} <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 /> PREWIT EXPIRES X YEAR FROM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. h <br /> Job Address 35100 ' City 1�erna�i� ..- Lot Size/Acreage 65o X V601 <br /> Owner's Name Vr, a Address C;- ot� j Phone <br /> �ySSS <br /> Contractor s� Address d Crag License No, r,/�S'�dOd Phon IS gZO� 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ r DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ (511 $'r-tv-)OTHER &!!� _-Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public El Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ­Approx. Depth € I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth f ` <br /> IA✓e-*+L ... vA ® Depth Filler Material & Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.I , <br /> Installation will serve: Residence— Commercial_ Other . <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments II <br /> PKG. TREATMENT PLT. ❑ Method of Disposal f <br /> m <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 cartify that in the perlormance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required 'nspections. Complete drawing on reverse side. ,h 1 <br /> Signed X Fes^-�"5r -- Title: leo�a.r#' Kti�-irtrQ¢�n�is 1 Date: <br /> FO EPAR M T USE ONLY <br /> Application Accepted by <br /> Date 2Z~ 4� res 17133 <br /> Pit or Grout Inspection by Date Final Inspection by, Date 2Z �G <br /> Additional Comments: <br /> Applicant - Return all 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 AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT N0. <br /> . EK 1324 IREV. x5l / 3! 7 �L v r[/—�-LV <br /> EH 14.20 <br />