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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 i <br /> PST_EXPIRES 1. YEAR FROM DAT. ' ISSUED <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 <br /> /Services. <br /> Job Address _ // Z� _kl4el City Lot Size/Acreage ! / - <br /> t <br /> Owner's Name Address -- ' �,„ , Phone �� K <br /> t , <br /> Contractor Address License No.� � 7'� Phoney_! � <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT C DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C7 OTHER C Monitoring Well ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l <br /> INTENDED USESi TYPE OF WELL PROBLEM AREAC NSTRUCTION SPECIFICATIONS_ <br /> L-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public CI Other R Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I lNo septic system permitted if public.sewer is <br /> available within 200 feet.]-4'n <br /> Installation will serve: Residence Commercial ther <br /> Number of living units: —IL Number of bedro s <br /> Character of soil to a depth of 3 feet: .. Water table depth v r <br /> SEPTIC TANK. B' Type/Mfg Capacity *C�' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well>e _A Foundation__,40 Property Line tr <br /> t <br /> LEACHING LINE C4�­No. & Length of lines _ T_otal length/size— <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well �� Foundations l Property Line �� r <br /> SEEPAGE PITS ILl/ Size Depth DeP — Number Number <br /> SUMPS f L3 Distance to nearest: Well /0 Foundation CPQ.. Property.*Line <br /> DISPOSAL PONDS O - a <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. - - i r � s -% . .. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thi-woi-k-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." t t <br /> The applicant must call for all r uire inspections. Complete drawing on reverse side.• w.-- t <br /> Signed X Title: _110a)N�i <br /> Date: <br /> FOR DEPARTMENT USE ONLY' <br /> A plication Accepted by Data <br /> A�_I_ Area <br /> f <br /> Pit r Grtiut Inspection,by C� _ Date " �.Final Inspection.by _ Date <br /> Additional Comments: .4 A/.. //•�E <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 i <br /> } <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE�i PERMiT N0. <br /> . EM13•24 fREV.riatss 111441/44 ! fit <br /> FH 14-26 C9 <br />