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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 /> HERMIT 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 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address //,C/! 1 l Z�Zz�Y Za--n-ey_�yQ�^ <br /> Cit Lot Slie/Acreag ��a L, <br /> Ow \ 4' ddress ���7n kf Phone <br /> 1 <br /> Contractor Address _ License No. Phone <br /> T11 <br /> YPE OF L/PUMP: NEW WELL ❑ WELL REPLACEMENT l-1 DESTRUCTION Out of Service Well <br /> PUMP INSTALLATION D SYSTEM <br /> � LREPAIR O OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK L SEWER LINES MLt e2_ DISPOSAL FLD.&2_�PROP. LINEW.Z <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_Z _'EL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' •CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial 0 Open Bottom ❑ Manteca i , Dia. of Well Excavation_.�: Dia. of Well Casing <br /> ,.l Domestic/Private Ll Gravel Pack n Tracy Type of Casing 'Specifications <br /> I'1 Public 1:1 Other I 1 Delta Depth of'Groul Seal Type of Grout <br /> 11 Irr,Bation __.Approx. Depth ._ l I Eastern Surface Soul Installed byI <br /> Repair Work Done .1:1 Type of Pump H.P. State Work Done _ <br /> ~Well Destruction Well Diameter Sealing Material 3 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSrALLATION I I REPAIRIADDITION I I DESTRUCTION ISI^tNo septic system permitted if public sewer is S <br /> available within 200 feet.l <br /> 1i Installation will serve: Residence Commercial_ Other <br /> i Number of living units: Numtier'df bedrooms <br /> l Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type'/Mfg Capacity No. Compartments <br /> PKG:TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE Ll No. & Length of lines �� �� _ ' Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> l SEEPAGE PITS 11 Depth _ Size _ _ Number C <br /> SUMPS 1.1 Distance to nearest: Well Foundation ` Property Line i (� <br /> + DISPOSAL PONDS ❑ I {� <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: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. <br /> tion laws of California." <br /> The appli nt must ` ired inspec o t raw n r�a se side. <br /> `Signedittf {e: ���h�-�/`z� Date: <br /> n. _ _ FOR DEPARTMENT USE ONLY <br /> Application Accepted " _ Date 12 Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments:^ <br /> Appliceaty-Ret WL1_l 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 ,FEE ' <br /> INFO AMOUNT DUE ` AMOUNT REMITTED CASH r RECEIVED BY <-L DATE »PERMIT NO. <br /> • E>tt]NIREY.tinsr ?V C1 /� 7 S L CI �1,96 200-13-a,31 �. <br /> EM i16•1e <br />