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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E"IRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby staple to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Han Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressCity Lot Size creage y/r <br /> ��.6. <br /> ;I <br /> Ow ars Name rI *ny15' Address <br /> Phone <br /> �-' 7_IL-lIdS C_eL Ca.J'_:__Address- fIZ1t cSltn S•rT.._/_�l-- License No. ti3e 2/a/ _Phone 1 '7v —2?1 <br /> CoAtrdUer- <br /> TYPE OF LL/Pt1MP: 11 NEW WELL t `� —WELL REPLACEMENT C] i DESTRUCTION ❑ Out of service Well ❑ <br /> ' OTHER O Monitoring Well C3 <br /> C• �' I PUMP INSTALLATION O 1 j SYSTEM REPAIR ❑ <br /> i. 1 r DISP1 SAL FLD. PROP. LINE sem._ <br /> DISTAN�E�TO'NEAREST; SEPTIC TANK SEWER LINES PITS/SUMPS <br /> w FOUNDATION AGRICULTURE WELL OTHER WELL <br /> �r _ <br /> WMENDED USE �TYPE OF WELL PROBIEM�REA CONSTRUCTION SPECIFICATIONS <br /> n Botto—m ❑ Manteca r Dia�of Well Excavation Dia. of Well Casing <br /> nl Industrial fli; t �TrtL1 Specilicalions WIA <br /> r Type of Casing <br /> ❑'Domestic/Private ❑ Gravel Pack O Tracy g Type of Grout pa'•�!' � <br /> I'I Public i ❑ Other ' '"f7 Delta IDepth of Grout Seal } -_ ,�' I <br /> I Iniloation _Appfox; Depth 1 I Eastern iSudace Seal Installed by .t_a <br /> Repair Work Dons U Type of Pump H.P. <br /> StH'te Work Done_ <br /> sealing Material a Depth I <br /> Well Destruction Well Diameter Filler Material L Depth <br /> DI � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I DESTRUCTION I avail ble11within 200 feet�l11 ed it public sewer is <br /> ,trtstasation will serve: Residence_ Commercial_ Other <br /> �Ntimbw o r Number of bedrooms 1 <br /> r ( I r table depth ' <br /> ,Character of sail to a depth o <br /> SEPTIC TANK. O •Type/Mfg ! Capacity No. Compartments 1 <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> t ! Distance to nearest: Well Qundation I Property Lina <br /> LEACHING LINE Ll No. & Length o t I Total longth/sire .. <br /> FILTER BED 0 Distan morsel: Wail I Roundation Property Line <br /> I <br /> 1 . <br /> { I " <br /> SEEPAGE PITS I Depth Sus Number( . <br /> SUMPS LI iDistance to mortal: Well I Foundation Property Line <br /> DISPOSAL PONDS „ <br /> I hereby comity that I hews prepared this application and that the work'will'be done in accordanc4 with San Joaquin county ordinances, state laws,and <br /> rules and regulations of the San Joaquin County - <br /> Horns 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 sh411'not <br /> orkmen's oompensgNon lows of California." Contractor's hiring or subcontracting signature <br /> employ any person in sash manner as to become subject to w <br /> certifies the following:1•1 comfy that in the performance of the work for whit'this permit is issued,'I shall employ Persons subject to workman's comparfsa . <br /> tion laws of California." li i f <br /> The applicant mus call for aN squired 'nspgctions. Comdata drawing I reverori <br /> Tide: ru Date: <br /> Signed.. i�-� <br /> I FOR DEPARTMENT USE ONLY <br /> u <br /> ;I - i Datdl Area <br /> Application Accepted by I <br /> I Date I �� Final Inspection by Dna <br /> Pit or Grant Inspection by <br /> Additional Comments: unit-tt,♦ �-4 3 � � � -s—� �D� ��--' _ _ .. _ <br /> _ .He -- ` <br /> '/Ippl3ca'dtTAe`turmm coiias to: Nan Joaquin County Pub11c Health r 1 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hasalton Ave.. P 0 Box 2009, Stockton; CAM95201 <br /> CK RECEIVED BYPERMIYNO[FEE <br /> EEAMOUNTE RAIIOUNT REMITTED CASH ER,1-i�taEV.lrxsl �c, . ase 3 3 (`f1,(`L 12- ta�la 3as1 <br /> EH 11.16 <br />