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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 EXPIRES 1 YEAR FROM DATE ISSUED <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br />'Job Address l �/1 �i�a� / City v ! /� Lot Size/Acreage <br /> Owner's Name �GG /ei�J Address�yx � rc<a,� 1611/`j Pho 7�s ST, <br /> Contract o _ Address License No. Phone�J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 Out of Service Wel <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHE Monitoring Well Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> Il Public f.lO her (l Delta Depth of Grout Seal T <br /> ..� —__ ype of Grout <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done FJ Type-of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diame-le Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer .s <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth _ <br /> SEPTIC TANK O Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Prb rty Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size __ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> smploy any person in such manngr as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br />:ertifies the following: "I certify ItAat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> ion laws of California." <br /> Fhe applicant must call for allquired ins eetions. Complete drawing on reverse side. <br /> Signed X Title: lr4,C <br /> Date: _ <br /> 0 OR PEPARTMENT USE ONLY <br /> kpplication Accepted by 5--' l 12- <br /> Date Area <br />'it or Grout Inspection by Date Final Inspection by/ C"f- Date <br /> 9 <br /> additional Comments: <br />�Pplicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> ob 160a e on Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AUi.NT REMITTED CK RECEIVED BY <br /> INFO CASH DATELOD <br /> PERMIT N0. <br /> C9 C (f <br />