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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> n 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s hereby made to San Joaquin County for a permit to construct and/or install the workherein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sh <br /> Joaquin County Public Health Servi ea.,/ <br /> Job Addressr / 4� 3/ �U /��/s <br /> City Lot Size/Acreage <br /> 1P <br /> Owner's Name Address Phone <br /> Contractor /lh Address License No: ry •K.4_PhoneJ ' 7 <br /> TYPE OF WELL/PUMP: NEW.WELL O WELL RE LACEMEt4T ❑ DESTRUCTION E) Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0THiR`tl Monitoring Well <br /> r."O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIES/SUMPS — <br /> INTENDED. U6E TYPE OF WELL PROBLEM AREA C_ONSTRUCTION;SPECIFICATIONS <br /> _ (l Industrials ❑ Open Bottom ❑ Manteca Dia. of Well Excav�lion t Dia. of Well Casing <br /> 11 Dofnestic/Private r 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public' 1.1 Other (I Delta Depth of Grout Sbel Type o1 Grout <br /> I,I'lrripation �_.Approx. Depth I I Eastern Surface Seal Installed by ' <br /> f{ gir Work Done U Type of Pump N.P. State Work Done _ <br /> 1Nt estruction O Well Diameter Sealing Material L Depth <br /> rY Depth Filler Material & Depth <br /> r <br /> TYi t SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I�(No septic system permitted it public Bawer is <br /> �t Available within 200 feet.) <br /> 14 n will serve: Ffesidetice 1, \ <br /> 7!!�p � Commercial_ Other r 'V <br /> Numliving unfits: ( Numbel of bedroo <br /> Charact�bf rfto a dept— feet: Water table depth <br /> SEPTIC TA Ki J,'rO. J"ype/Mfgy. Capacity <br /> No. Compartments <br /> PKG. TREAT4 if Lt.b Method of Disposal Llewr <br /> Ak <br /> r3 Distance to nearest: Well Fbundation 1010/ Property Line <br /> LEACHING LINE CLQ Mo. & Length of lines TAbi length/size <br /> FILTER BED O Distance to nearest: Well ,�� Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size llumbDr <br /> SUMPS LI Distance to nearest: Well QD Foundation !dd/ Property Line4 —b <br /> DISPOSAL PONDS O <br /> I hereby cenify that I have prepared this application and that the work will be done iii 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 workmen'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, 1 shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant mu"11 for irad ' spections. Complete drawing on reverse side. <br /> - Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �� �'� - .��--� Data </ — / Area / l <br /> Pi or Grout Inspection by ate + !2� Final Inspection byDate <br /> Additional Comments: j <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Boz 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> 1 74 4 26 <br /> reFv r,�sr � t I.� 6� �: b� �� WJ:'3:`� <br />