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l APPLICATION FOR PERMIT <br /> # SAN JOAQU.LN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I RONM&ITAL�AEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> _IT-EXPIRES 1 YEAR FROM DA2:E 1Sb9UED <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 /> I 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. stctdL.. <br /> Job Address1 1 , City Lot Size/Acreage <br /> CD tr <br /> Owner's Name hone <br /> _ V✓o!III �+SQ r1.��{I!G �A�1 :rA� 0+�, _ �+�r+ctlr�P� ._�,r;, _ . <br /> con t I ate Address F?Q&. l!9'Y--17 q_� �nse r [E,-C 7IAZ3Z3Pi ne _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Frout of service Well ❑ <br /> PUMP-INSTALLATION'E 1. SYSTEM REPAIR 0 OTHER ❑ Mofiit$ring Well G7 <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 PR6BLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [:] Domestic/Private ❑ Gravel Pack ❑ Tracy_ Type of Casing ' ,r Specifications <br /> f'1 Public Cl Other f-i Delta Depth of Grout Seal t- Type of Grout <br /> I I Irrigation _.Approx, Depth I I Eastern Surface Seal Installed by- <br /> Repair <br /> y Repair War e ❑ Type of Pump H.P. State Work Done <br /> e nuctian� Well Diameter <br /> r Sealing Material & Depth <br /> Depth I'a9 . Filler Material 6 Depth - - <br /> YPE OF S PTI ORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I Z .iNo-septic.system permitted if public sewer is <br /> ;available within 200 feet.) <br /> Installation will serve: Residence Commercial" Other <br /> Number of living units: Number of bedrooms wy' <br /> Character of 6011 to a depth of 3 feet:..• W to er Sable depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity �-! No. Compartments <br /> PKG. TREATMENT PLT, ❑ + I 'ti - \moi Method of Disposal <br /> Distance torn crest: Well Foundation operty L ni e- ` <br /> f LEACHING LINE ❑ No. & Length of lines V Total length/'size" <br /> FILTER BED n i Distance to nearest: Well`% Foundation -�' Property Line E <br /> SEEPAGE PITS l I Depth Size Number -F <br /> SUMPS ( LI t Distance to nearest: ? Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t. .I <br /> I hereby certify that I have prepared this application and that the 1work will be done in accordance with San 16aguin county ordinances, state laws, and', <br /> rules and regulations of the San Joaquin'County Il ; <br /> Home owner or,lic ag is signiture certifies the following:t't certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per n in such nner as to`6ecome subi6et to workm ' ompensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the lowing: "I ce y that in_th`perfofmwx 0 of ther for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California." j <br /> The ap is ust c r all r C ' Cam ete drawing oai t <br /> 1-2 Signet Title: Date: <br /> l f�, FOR DEPARTMENT'USE ONLY <br /> Application Accepted by t�� 4Q�,y��� Date r �7 r _ Area ` <br /> Pit or Grout Inspection by I Date Final Inspection by Date 3 17 <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 /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> + EM13-21(REV. /n5i /�' //� <br /> EH 14-26 C/ !(� <br />