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�aivy"iuAQUTA'U U i'S�. yuisi;li: i ii.°r�7r -Ra' ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOA 2009, STOCgTON, CA 95201FILE COPY <br /> � <br /> PFJWIT RES 1 YEAR FROM DATE <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 is made in compliance with San Joaquin County Ordinance No. 549 and 62 and the Rules and Regulations of San <br /> Joaquin County Public HAlth Services. <br /> Job Address City <br /> t Lot Size/Acreage <br /> Owner's Name �3� Address ` �"I Phone <br /> / `.. r Address ti . . .I�icanse Ivo.�f,!�(f4 .P.hone. <br /> Contractor R <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ S TEM REP R ❑ OTHER ❑ Monitor Ing Well i] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION. AGRICULTURE W. OTHER WELL PITSlSUMPS E <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> Cl Industrial O'Open Bottom ❑ Manteca ia. of Wall Excavation Dia. o}1Nell'Easing ' <br /> n Domestic/Private 0.Gravel Pack ❑ Tracy Type o Casing Specifications <br /> FI Public I:I Other I-1 Delta Depth f Grout Seal Type of Groui <br /> I I IrriS7ation j Approx. Depth I I Eastern,, Surface Seal Installed by I <br /> ,Repair Work Done; ❑ Type of Pump H.P. StateiWo(k Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Finer Material 5 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I I DESTR T10N I I iNo septic sy tem permitted it pub is s4is <br /> j av it <br /> Is wi 200 f at.) i <br /> Installation will serve: Residence_L-' Commercial then <br /> N�'� <br /> Number of living units: 6Number of bedrooms , <br /> Character of soil to a depth'ol`1,feet: Water table depth <br /> SEPTIC TANK. ❑ Type/INfg Capacity Aff lY Q No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of�DI sal <br /> Distancl to nearest: Well�Q Foundation Property Line J <br /> LEACHING LINE S No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel Foundation Property Line I <br /> � t <br /> SEEPAGE PITS Depth V" ~�0 _Si2e 4 Nu er <br /> SUMPS Cl Distance to Tmrretit: . 'Well _91t <br /> DISPOSAL POND ❑ �� <br /> I hereby certify thalt I have prepared this application and that the..vyork will be done in accordance with Sin Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin"County i <br /> Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is i16ued, 1 shall not <br /> employ any persontin such manner as to become subject to workman's compensation laws of California."0ontiactor'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 lifamia." <br /> The applica usl call fo required 'nspections. Complete drawing on reverse side. { <br /> I Signed Title: ` ` Date: <br /> FO r-DEPARTMENT USE ONLY <br /> Application Accept'd by Date a1 •1 Area <br /> Pit or Grout Inspection by Date Final Inspection by�s� <br /> Additional Comments; j <br /> Applicant — Return all copies toi­ San Joaquin County Public Health <br /> Services; Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA szbi <br /> FEC AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N6. <br /> INFO <br /> I <br /> In .+ EH13-24(REV.if <br /> A st s 91 -r <br /> + EH 94.26 <br />