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l APPLICATION FOR PEIriwy <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> > P O BOX 2009, STOCgTON, CA 95201 <br /> REMIT RES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby msde,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 Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name �l+d � ddress Phone <br /> Contra Clor� fL_Rk10 .I` Address License Nb r 10 '"'Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out.of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well <br /> is <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LWES DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L-1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing Specifications <br /> 1'1 Pubf+c I=1 Other n 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 U Typo of Pump N.P. State Work Done <br /> & <br /> Well Destruction O Well Diameter Sealing Material�_ Depth <br /> l" Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> �� available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other l 5.• •,,_, <br /> _ <br /> Number of living units: Number of bedrooms <br /> 1 <br /> Character of soil to a depth of 3 feat: Water table depth <br /> SEPTIC,TANK. ,2r Type/Mfg Capacity AZO ONo. Compartments <br /> � PKG. TREATMENT PLT.❑ �r Methodaf Disposal <br /> Distance to nearest: 11VeII Foundation Property Line <br /> LEACHING LINE ;No. &Length of lines 2, Total lang.th/size` -a <br /> i <br /> FILTER,BED ❑.—distance to nearest: Well /QQ Foundation �t7:� Property Line <br /> rill <br /> SEEPAGE PITS De th 5 Size .33 R <br /> p N�mber <br /> SUMPS Ul Distance to nearest: Well Foundation 6� Property Line <br /> DISPOSAL PONDS ❑ <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'subiect 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 applicWmtfor ail r ' ' enspectizpb. Complate drawing on reverse side. <br /> Signe Title: Date: <br /> . FOR PEPARTMENT USE ONLY <br /> Application Accepted by !� 't� Date "' S) Areaj. <br /> Pit or Grout inspection by Date Final Inspection by Date U <br /> Additional Comments` .' Y ;l S l yy <br /> 7: Applicaa%- Return e.4. copies to: San Joaquin County Public Health <br /> t Services, Environmental Health Permit/Services <br /> t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE f ERMIT'N0. r <br /> FH t1 24 lAEV.t/x51 . �att�U �� (v�33 SLO S 0^�� <br />