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k �E <br /> 1 APPLICATION FOR PERMIT <br /> i <br /> s SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> #7 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E_ HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PEMITIT EXPIREf I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> b <br /> Application to hereby made.to Stip Joaquin County for a perclt to construct and/or install the work htYele deeeribed. 'lhia <br /> application is made in compliance with San Joaquin County ordinance No. 5t,9 and 1852 and Lhe Rules and Regulations of San 3 <br /> Josquin County PublSc Health Services. r <br /> Lot Size/Acreage <br /> Job Address r!--., �- ,CYf n n I .'7 7T ! -r.+�---•'---- CitY � l�--- - a <br /> f <br /> AddressPhone <br /> r' — <br /> ' <br /> Owner's Name . <br /> Contractor <br /> Address i�Y License None .� <br /> t--- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U.4uL of-Berwice We11..❑ 's <br /> OTHER ❑ MoniWring Stell <br /> - PUMP INSTALLATION SYSTEM REPAIR 0 < " <br /> .! _ <br /> DISTANCE TO,NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD.' PRDP:'L1NE h <br /> t r PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL i <br /> n <br /> 1 INTENDFOJUSE TYPE OF WELL PROD LEM AREA CONSTRUCTION SPECIFICATIDNS <br /> D a.of Werl Cas <br /> ❑Industrial ❑Open Bottom ❑Manteca Die.of Well Excavation ng <br /> 1 Type of Casing Specifications—L <br /> IN Oomesticiprivate ❑Gravel Peck L7 Tracy g— Type of Grout <br /> t i-Public 0 Other i�C71ta Depth of Growl Seal <br /> Irrigation - _Approx. Depth I I Eastern Surface Seul Installed by - <br /> _ _5 P Stara Work DonaY h - <br /> } Repair Work Done ❑ Type of Pump �t,�rrtcsrsrt H.P'. - <br /> j ¢g. Sealing Material k Depth - ` r <br /> Well Destruction C3 Well Diameter <br /> l Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR!ADD:TION I F DESTRUCTION t 3 IND septic system permitted f ptrbl-C sewer is <br /> ¢ available within_240 feet.) <br /> f - - - <br /> j Irstollation will serve: Residence Commercial'^ Other _ - <br /> �`^. ms ' -$ <br /> 4 Number of living units: Number of bedroo <br /> E Water tette depth <br /> -Character a111lsoil to a depth of 3 leer: _ <br /> TANK'1 ❑ Type/Mfg Capacity Na.Cn <br /> omPaments.- t <br /> Method of Disposal ti <br /> PKG.TREATMENT PLT.❑ u <br /> Distance to nearest: Well Foundation- Property Line - e <br /> I �+ .I - Total Fengthlsiie - - <br /> -Y{ ' LEACHING LINE _ ❑ No.5 Length of lines - ; <br /> FILTER 6E0I� l=1 Distance to nearest: Wall - - Foundation Properly Lin6 <br /> l - _ - - <br /> Number, } <br /> i SEEPAGE PITS 11 Depth Sire <br /> SUMPS LI Distance to nearest: Well Foundalion _ Property Line f I <br /> 615POSAL PONDS ❑ <br /> -E 11.1.111 certify.that I have prepared this ep.t=r,uon and that tha work will be done in accordance with,Sen Joaquin.County'ordinances,aceta laws <br /> a rules and regufa[iorrs of the Sen Joa4uin Cow ty ' "-- <br /> Home owner of licensed agent's signdmre cenifics the fall nv,,ng:-"I certify that in the performance of the work for wretch this permit is issued <br /> ,1 shag re <br /> a 'j employ any poison in such mennar as to become subject to workmen's comparsat:on Laws of Catilornia. ConTractofs hiring or sub-contracting signature <br /> cent to*the IOBo, np:"1 ce;ify that in the performance:ol the work fbr which this permit is issued,f shaG'.mploy t7ersons subject to workman s compMN <br /> 'tion lawsofCalifornia." <br /> ° 1g <br /> r The apphcanl ust call for all required'mspecr ry! Complet drawing an/r ✓arse side. <br /> ! F <br /> - F DEPARTMENT USE ONLY <br /> k! <br /> Dale Ares <br /> Aron s <br /> Application Accepted by <br /> Date Final tnspection'by .Deta �; . <br /> w Ph or Gfout Inspection by <br /> Ef` Add'nionel Commenic ' <br /> { Applicant -'Return all copies to: San Joaquin County Public Health <br /> Servicee,.Envircamental. Health Permit/Services <br /> - -.. 1602 E. F.avelton Ave., P 0 Mx 2ne9, Stockton, CA 45201 <br /> � C +VED BY DATE PERMFT'NO.� <br /> AMOUNT DUE AMOUH7 REMITTED CASH <br /> .lNF4 P - <br /> - qw <br />