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APPLICATION'' Opl. PERMIT j <br /> 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 /> 1i <br /> PERM11 EXPIRES 1 YEAR FROM DATE SUED <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. <br /> Job Address c, <br /> // <br /> City IIN 0A Cit - - Lot Size/Acreage <br /> • <br /> Owner's Name <br /> Address �1' 1 !' J1/� .� Phone I� <br /> i eI ry_1�P� <br /> -"Contractor r - Address - License No - -Rhone <br /> TYPE OF WELL/PUMP: NEW WELL 1­1WELL REPLACEMENT ❑ DESTRUC710N ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ti i. OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLIT. — PROP. LINE _ - - <br /> ------*—­ —1F0UNDATION- -- A- ICULTURE WELL OTHER WELL PITS/SUMPS s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t } <br /> ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing' I <br /> CI Domestic/Private Ci-Gfavel-Pack— - ❑ Tracy Type of Casing Specific4fibris <br /> I'1 Public LI Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Saul Installed by t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Watt Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth { <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION-4 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> d. available within 200 feet.) ,�(1 <br />. installation will serve: Residence_X,. Commercial 3 Other - _- <br /> Number of living units: •�L Number of bedrooms ?i� 1 <br /> � <br /> Character of soil to a depth of 3 feet: �r , - - - — Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity_ No. Compartments �. <br /> Method of Disposal. <br /> -. PKG. TREATMENT-PI-T._ ❑ <br /> `°bistance to nearest: Well Foundation Property Line <br /> Ila <br /> 10 <br /> LEACHING LINE ri No. & Length of-sines r ` Total lengthlsize <br /> FILTER BED rt Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS h{I Depth Size �21 R_ - Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 subfect to workman's compensation laws of California,"Contractor's hiring of sub-contracting signature <br /> s 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 r all requ' ed pectio Complete dra ' g on reverse side. <br /> 14 Sign Title: Data: <br /> �. <br /> �RDEP�ARTME�NTUISE ONLY ` <br /> �^ plication Accepted by Date, <br /> ,,�� ` 0 Area 4 <br /> F Pit or rout Inspection by �� C� Date ~)� inal Inspection b �'� <br /> dditional Comments: <br /> I <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 /> FE AMOUNT OUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> INP G f <br /> + EH U-24 1REV.1 N SI 7� � �/ <br /> EIS 14.26 <br /> 1 <br />