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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PRONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i - PMUIT EXPIRES 1 YEARZ)ROM 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 ccetpliance with San Joaquin County Ordinance No. 549 and 1862 sod the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address d City�aJ•l Lot Siz Acre <br /> Owners Name . {�r t.i�h.a. ' Address — Phone <br /> I <br /> r <br /> Contractor XL, E&Sia—.Cr1n ' _ Address 2 License NO / Phone <br /> YPE OF WELOPUMP: _ ._ _ NEW WELL 9 WELL REPLACEMENT Cl DESTRUCTION L7 Out of Service Well ❑ <br /> - <br /> PUMP INSTALLATION ID SYSTEM REPAIR ❑ � OTHER ❑ �itoring Well � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.� PROP, LINE IS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> 0 Industrial Open Bottom ❑ Manteca Dia. of Well E>tcavation Dia.01 Well Casing <br /> j IP(Domesliciplivate Cl Gravel Pack ❑Tracy Type of Casing eel_ Specifications <br /> ['1 Public Cl Other n Delta Depth of Grout Seal � " Type of Grout <br /> I I Irrigation _.Appro'�Depth ( Eastern Su ca Seal installed by -- <br /> Repair Work Done U Type of Pump - H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing terial & Depth V <br /> Depth t biller Material & Depth O <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> 1 •.3�h available within 200 feet.) �J` <br /> } Installation will serve: Residence Commercial— Other - <br /> Numberv livil ng ttni Number of bedrooms 1 <br /> Character of soil to a depth o t ' 1.--... Water table depth <br /> SEPTIC TANK. O Type/Mfg 3 Capacity No ments <br /> PKG.TREATMENT PLT.❑ �;f ! Method of Disposal <br /> Distance to nearest: Well a' Property Line <br /> LEACHING LINE L1 No. 8 Length of lines '�+ Tota size <br /> FILTER BED F] Length <br /> to rte Well _ Foundation Property L! <br /> [ Y <br /> f SEEPAGE PITS 9plh '1 Sias Number <br /> SUMPS Ll -Distance,to nearest;' Weil, —Property Line <br /> DISP ONDS ❑ <br /> I hereby certify that 1 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 cenify that In the performance of the work for which this permit is issued,1 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 /> certifies the following:"I certify that in the performance of the work-for which'this'parmit is issued,I shall eMploy persons subject to workman's comp,nsa: <br /> tion laws of California." 1 1 <br /> t <br /> I The applicant mus 11 for all required ins actions. Complete drawing on reverse side. <br /> `r7�� � �� � I7- Qo <br /> Signed X �' Titre: kC.�/� Date: <br /> DEPARTMENT U.SE ONLY I <br /> Applicatlo Accepted by AJf- DateiArs, _. <br /> Pit o rout rispection - Dat _z`� � Final Inspection by Date <br /> Additional Comment <br /> Applicaat_,fte turn all copies to: Ban Joaquin County Public Heah` <br /> `i.. Services, Environmental. Health Permit/Services <br /> 1601 E. Bazelton'Ave., P 0 Box 2009, Stocktonr,CA. 95201 <br /> 1 FO AMOUNT DUE AMOUNT REMITTED` .CASH RECEEVED BYE- DATE PERMI7'N0. <br /> -- ►^ <br /> .EHl3.2ilREY.t/x6t t1yy'�'-�� 30116 <br /> EH Erle l 1/�./ i <br /> 1 <br />