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f APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL ELEALTH DIVISION <br /> • 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FRQI�l)ATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application Is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County " .. <br /> Job Address 6'855 W. Eight Mile Road CityStgckton Lot Size/Acr"e <br /> Owner's Name . U.S- Sprint _ _-_- _ Address P.0—ROX-11490 Kansas C;tom. Phone - <br /> MO 64114 <br /> Contractor Address License No. Cr,?#552198PhonJ 916)373-111 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER EXMSpoItoring Well lgs [D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 811 Dia. of Well Casing <br /> XI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I1 Public n Other n Delta Depth of Grout Seal NIA Type of Grout _ri-morlt <br /> I I irrigation .4RApprox. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done S <br /> Well Destruction ❑ Well Diameter Sealing Haterial !k Depth 4-5 Sack Camebt Gratif to full dept <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 fest.) <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 table depth <br /> SEPTIC TANK ❑ Type1Mf9 Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of,lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size 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 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 /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> 5ignadTitle:�sfL.Fc'Ls.h. cr GlI�J_'R�'`�• -&--- 'A�Drate: 1Z 415:) <br /> C. FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> dditional Comments: <br /> a <br /> Applicant -� Return all copies to. San Joaquin County Public Health <br /> Services, Ewrirozsmental Health Permit/Services <br /> 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTER CASHCK�8RECEIVED BY DATE PERMIT'NO. <br /> • EN 13.24 IREV,flee) <br /> EN i4•2a <br />