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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ;• ,tom-. . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOC%TON, CA 95201 <br /> • ' M' PERMIT MEIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> tApplication is hereby.mede to San Joaquin County for a permit'to construct andlor install the work herein described. This <br /> application is made in'bo liance .wlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. <br /> Job Address ; "� T(� City j Lot Size/Acreage <br /> Owner's Name ' Address o(r�� �/l!/I7=Fi J Phone 33 ico <br /> Contractor Address % Icense No. hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO_N O Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR (2OTNER E] Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES DISPOSAL FLO. PROP. LINE r <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t, i-) Industrial ❑ Open Bottom ❑,Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1.1 Domestic/Private r.y ,O_Gravel Pack ❑.Tracy�� _ Type of Casing Specifications <br /> i I'1 Public 1-1 Other 1-1 Delta Oepth of Grout Sealf-- Type of Grout / <br /> I I Irrigation t Appro>i Depth 11 Eastern Surface Seal Installed by -� <br /> Repair Woik Done([],!Type of Pump ?° H:P.` Lf State Work Done_ <br /> I Well Destruction O 'Well Diamet�e'i~� �" .S �al )faterial,i_Aepth <br /> y... w <br /> Depth `� � -",Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION_ .._REPAIR/ADDITION DESTRUCTION AlNo septic system permitted if public sewer is <br /> # 'vailable within 200 feet.) <br /> Installation wilt serve: Residence Commercial Other <br /> i Number of living units: . Number of bedrooms � <br /> U <br /> Character of soil to a depth of 3 feet:' t Water table depth <br /> SEPTIC TANK O - Type/Mf VAI Capacity I VO No. Compartments 2 <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> L.Distance"to nearest: Well 1���E% Foundation Prop@rty Line <br /> LEACHING LINE ❑ No. &'Length of lines I —t � Total length/size <br /> FILTER BED O Distance fa nearest:` -Well o Foundation Property Line <br /> SEEPAGE PITS [ I DepthSize 3 / Number (Y" <br /> n. SUMPS Ll Distance Ato eerest: I Well Foundation/ Property Line ^ , <br /> 3 DISPOSAL PONDS O (` T <br /> i <br /> rF I hereby cenify that I have prepared this application and that the work will be done in accordance with San_.Joaquin county ordinances, state laws, and <br /> >T 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,I shall employ persons subject to v rkman's compensa- <br /> tion laws of California." f <br /> The applicant must for all require 'tsps t s:'Complete drawing on reverse side. <br /> Signed k li /�/�� Title: - Date: /� '74 <br /> F R DEPARTMENT USE ONLY <br /> 'Application Accepted by �� F„ M� l Date L�4—_S Area <br /> Pit or Grout Inspection by Date Final Inspection by _S2 �at7'_ Date <br /> Additional Comments: <br /> t Applicant - Return all copies to s San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services Sf <br /> 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO {AMOUNT DUE AMOUNT REMITTED CASH is R/EECCEIIVED BY r DATE PEAMI7 N0. <br /> EH14-211REV.tine '� <br /> EH t�-20 <br />