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k <br /> APPLICATION FOR PERMIT <br /> r <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 /> XP RES 1 YEAR R M DATE ISSURn <br /> (Complete in Triplicate) <br /> I 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 Ser .,ices. r <br /> I Job Address _ ;p' (� `7,6) e[L City G� t Lot Size/Acreage <br /> k pp rti tot, { c e Phone <br /> t?CU f�Ct ICe_ j& Address ---I L <br /> Owner's Name � F <br /> ) <br /> Contrataor_ - t h -Address-- •*d- License Not_W - Phone _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CIDESTRUCTION>dZlt of Service Well ❑ <br /> F PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER;❑ <br /> Monitoring Well <br /> d , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C 1 Industrial ❑ Open Bottom ❑ Manteca pia- of Well Excavation Dia. of Well Casing <br /> [1 Domestic/f Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F I'1 Public 1-1 Other f1 Delta Depth.of Grout Seal Type of Grout <br /> 5 <br /> 11 Irrigation w.Approx, Depth I I Eastern Surface Seal Installed by t T <br /> Repair Work Done ❑ Type of Pump �,, r H.P. '1 - State Work Done �` <br /> + Well Destruction X Well Diameter 1 y< -- Sealing Material & Depth <br /> l Depth Filler Material & Depth rsn <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> I available within 200 feet.) �. <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 labia depth <br /> SEPTIC TANK -❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS 11 Depth - Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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 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 /> i The applicant must call for all required insPections. Complete drawing on reverse side. f t <br /> Signed <br /> Title: bate: t A <br /> R DEP -USE ONLY <br /> Applicetjon'Accepted by Date Area <br /> f Pit or Grout Inspection by Date Final inspection by Data <br /> f <br /> ' Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ' <br /> I Services, Environmental Health Permit/Services ; <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> )NFO ��rJ <br /> r + EM 13-24 iREV.I/K51 � <br /> h `"�-� LCkVNQ � •�� � �� � <br /> EH 14.28 _ it <br />