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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 /> gENIT EXPIRES 1 YEAR FROM D TE 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 He°alth Services. <br /> Jots Address Z 7L/t! r]' M� (0% City if �2 L(4 <br /> ot Size/Acreage <br /> ! <br /> Owner's Name / Address %G T?& (iU1�tV Phone <br /> Contractor <br /> Address Q / Lsc�¢ No. L 7J Phone <br /> TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> i <br /> PUMP:INSTALLATION ❑ SYSTEM REPAIR �� OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLD. PROP, LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 <br /> [ omesiiclPriv,te Ci Gravel Pack ❑ Tracy Type of Casing + Specifications <br /> I') Public Cl Other n Delta Depth of Grout S fial Type of Grout <br /> Qrrigation ........Approx. Dep h I I Eastern A dace Seat l stalled by C <br /> Repair Work Dnne}-[ Type of Pump -FicP: r�' t�0f)4-3 --State Work-Done= <br /> Well Destruction ❑ Welt Diameter Sealing Material & Depth <br /> # Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is <br /> I availabla,,within 200 feet.) <br /> Installation will sirve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms t <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. ❑ Method of Disposal <br /> x Distance to nearest: Well Foundations Property Line <br /> LEACHING LINE L-1 No. & Length of lines, _I Total length/size <br /> FILTER BED i n r Distance to'nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I 'Depth Size Number <br /> SUMPS Ll -Distance Lto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby canify 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 /> Homeowner or lic is 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 pe n in such me er as to become subject to workman's-compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the Mowing: "I certify at in the perfor ante of ork for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion�laws- -C-alitorni <br /> The appli ant must' all require ns ate awing 041IP7 <br /> side. �I <br /> Signed Title: Date: 7— L t� <br /> ' DEPARTMENT USE ONLY <br /> Apptii atlon Accepted by Date + Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 AMOUNT DUE AMOUNT REMITTED CK 41 RECEIVED BY DATE PERMIT NO. <br /> INFO ) CASH 77 <br /> . E1 -211REV.I/K51 l- S ,Q LV `J�'�Q �� r 193 <br /> EH 214.26 Lis <br />