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APPLICATION FOR PERMIO <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATfi <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 1e made in compliance with San Joaquin county OOrrddinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> Se/ryi�ce,�. a��1�' '�`�/' <br /> Job Addrssil'2 �/��J�)> l,/ U�W//Cf..1'L�.fl / City^ Lot Size/Acreage <br /> Owner's Name � w` �(i(�t-r!n r.�t"P-Addressry2,� ( � 0�_ Phone?� <br /> CQ `1/G�y CA/liiLy <br /> Contractor lS%= 5565yS <br /> PAddress-Address 1° 9 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTT^EREPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION � AGRICULTURE WEL OTHER WELL V PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS ' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav iio �4� Dia. of Well Casing <br /> )4-Domestic/Private jR4-Gravel Pack ❑ Tracy Type of Casinge <br /> PI Public 1.1 Other TypeSRecif Gro syw; <br /> � / //j�Delta Depth of Grout Seal 'V_ Type of Grout <br /> I I Irrigation . .Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> 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: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. i Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I Depth Sire <br /> SUMPS — Number <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 1 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 subcontracting signature <br /> canities the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons su <br /> tion laws oEIZ <br /> 1119 mull. bject to workman's compensa- <br /> The applicast call f 11 r uired in tions. Complete drawing on reverse side. <br /> Signed Titledw� C <br /> FOR DE ARTM BE ONLY <br /> Application Accepted by <br /> Date � � � Are 3 <br /> Pit or Grout Inspection by Data <br /> 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 gMOUN I DUE =F0 <br /> INFOE PERMIT'N0. <br /> EH IiN IaEy.i/x5l Cy , q_l� co q1) '1k <br />