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APPLICATION FOR PFRi�dXT„F { <br /> . <br /> *'s' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVrSION <br /> '1601-E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ,� � RMTT EXPIRES 1 YEAR FROM DAM—US UED <br /> /J0A (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 flan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> iltHealth Services. <br /> ( <br /> b Address �v_ t O ` v • V"'� City e_-S- � i Lot Size/Acreage 10 G.C_ <br /> Owner's Name C' r Address 1 \ ` '�r Phone <br /> contractor \' Address ` t �' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WEi L ❑ LL REPLACEMEN F-1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP R ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINE DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ! ❑ Manteca <br /> F12 <br /> . Well Excavation Dia. of Well Casing <br /> [7 Domestic/Private ❑ Gravel Pack 0 Tracy ype o Casing Specifications <br /> I'] Public 11 Other [7I Delta Depth o Grout Seal Type of Graut <br /> I I Irrigation —.Approx. Depth I I Eastern Surface S al Installed by <br /> Repair Work Done ❑ Type of Pump <br /> IP <br /> State Work Done <br /> Well Destruction ❑ Well Diameter sling Material Depth <br /> Depth I Filler Material & DVth t_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADD�ITfON i I DESTRUCTION I I (No septic system krmitted if public sewer is <br /> available within 200 feek.) , <br /> Installation will serve: Residence�L� Commercial_, Other 1 <br /> t Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: cx fAw` Water table depth <br /> SEPTIC TANK. D Type/MfgQ•� .L ^�. �� Capacity `��Cs� No. Compartments <br /> C2c c�. <br /> PKG. TREATMENT PLT. ❑ Method of pisposa�,, S <br /> _.._._., _.___. <br /> Distance to nearest: Well{' _3S Foundation �-� Property Line f ©� <br /> i LEACHING LINE � No. & Length of Ii es Total length/size D <br /> FILTER BED ❑ Distance to nearer: Well Foundation 3Q Property Line Z00 <br /> SEEPAGE PITS 14 Depth size _ Number. ... <br /> SUMPS L1 Distance to nearest- Well 52 O 0 Foundation 130 __ - Property Lina <br /> DI L 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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." III <br /> The applicalIT must call for I required inspections. Complete drawing on reverse side. <br /> VI.-Signed C II Title: Date: �� d <br /> OR KPARTMENT USE ONLY <br /> Application Accepted by Date 3�a -1 VA Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009,'Stockton, CA 95201 <br /> INEE UNT DUE AMOUNT REMITTED CASH RECEIVED BY []ATE c PERMIT'NO. <br /> + EH 17.24 TREY.rirs� b��g Z <br />' EH 114-26 l <br />