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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 /> t <br /> PERMIT EXPIRES 1 YEAR FRAM DATE IMED <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r <br /> Job Address 1 - 6-&A A� --- ._ City Lot Size/Acreage <br /> Owner's Name _/1E( � [� Address Sri-. Phone <br /> P7 on <br /> Contract 1L��- S Address: �✓ ____ License No Phone V5 cZ2,2r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION FffOut of Service Well ❑ h `' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ElMonitoring Well ❑ /]� <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE V <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA `CONSTRUCTION SPECIFICATIONS 1J�+ <br /> f] Industrial ❑ Open B_ottom ❑ Manteca Dia.-of Well Excavation Dia. of-Well Casing <br /> n Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ' I'1 Public 17 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> ° & z. <br /> Well Destruction (fY Wel! Dia er � Sealing Material Depth <br /> _ <br /> Depth 7 J° Filler Material dr Depth <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> i available within 200 feet.l <br /> Instal will serve: Residence_ Commercial T Other <br /> Number of living Number of bedropms <br /> r <br /> Character of soil to a dept feet: Wa epth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well � ndtio. Property Line <br /> , <br /> LEACHING LINE ❑ No. & Length of Ii Total length/size _ <br /> FILTER BED Cl Distance earest: Well Foundation erty Line <br /> ? SEEPAGE7���Distance <br /> Depth Size Number <br /> SUMPS to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ j ` <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, d <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the following: "! certify that in the pePrformance of the work- for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman'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 workman's compensa- <br /> tion laws of California. <br /> Thea lican us ail for all r uir <br /> pp ed napectians. Complete drawing on reverse side. <br /> I`Signed Title: _/r,L(fei/M Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~� Area <br /> Pit or Grout Inspection by C Date Final Inspection by Date d' 2/ <br /> Additional Comments: I I ✓ ipft <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> i Services, Favironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-21(R V.i9�- <br /> EH 13.24 <br />