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APPLICATIONFOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 <br /> ENVIR6NMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BO%� 2009, STOCKTON, CA 95201 r <br /> u <br /> ,PERMIT EVIRES 1 YEAR FROM DATE ISSUM s <br /> i� (Ca pfar a permit to lete in Triplicate) <br /> Application 1s hereby made to San Joaquin County construct and/or install the work herein described. This <br /> application is made in compliancejvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address t City Lot Size/Acreage <br /> I?�o Irts+er. Address �� Phone r <br /> Owner's Name -- -_ <br /> 11/ � / ,w License [Vc.A!�n�Phone - ` 2Z 7d7 <br /> Contractor[� YJN ?ge_Sseste,�r, Address <br /> TYPE OF WELL/PUMP: _� .._NEW.WELL.G Service Well <br /> ' ;WELL REPLACEMENT.O .j -DESTRUCTION,O,Out-.,�aitoring Well C7 <br /> PUMP INSTALLATION O SYSTEM REPAIR El OTHER C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 1-0 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECiFICATIONS1 <br /> Industrial O Open Bottom O Mameca Dia. of Well Excavation t Dia. of Well Casing <br /> 1 Specifications p <br /> ate ❑ Gravel Pack ❑ Tracy <br /> (1 Domestic/PrivType of Casing J <br /> ;'1 pt,bl;c 1_1 Other M Delta Depth of Grout Seal Type of Grout i <br /> I I Irrigation —..Approx. Depth t I Eastern Surface Seal installed by t - <br /> Repair Work Done U Type of Pump 1H.P. & Depth State Work.Done <br /> Sealing Material _ 4W <br /> Well Destruction O Well Diameter <br /> Depth Filler Material i Depth ; <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAiRIAODITIONY DESTRUCTION 1 I.INo septic system permitted if public sewer is <br /> 'available within 200 feet.) I <br /> t <br /> Installation will serve: Residence'J Commercial J Other <br /> Number of living units: Number of bedrooms, t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg f - - - Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ " Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t 11 <br /> LEACHING LINE No. & Length of lines' J�- Total length/size <br /> _ 1 <br /> FILTER BED O Distance to nearest: Well_ Foundation JId" <br /> � Property Line �� I <br /> SEEPAGE PITS �,t Depth f r�„a'S Size Number <br /> Line �d <br /> SUMPS LI Distance to nearest: Weft eo0 -fi Foundation .-'7r?` Property R, <br /> DISPOSAL PONDS ❑ ' <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, a <br /> rules and regulations of the San Joaquin County <br /> i Home owner or licensed agent's signature'canifies 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 bm <br /> ecoe subject toorkmen's compensation laws of California.""Contractor's hiring or subcontracting signature 1 <br /> i <br /> certifies the following: "I certify that in the pertormance of t e work for which this permit is Issued,I shall employ persons subject to workman's compensa\GGGV` <br /> tion laws of California." <br /> The applican must call for al r wired inspections. Complete drawing on reverse side. <br /> Signed <br /> /Title: �s.A.-A'- Date: 9a <br /> OR DEPARTMENT_USE A.NLY ti <br /> - -' _ —2 a Area 3 <br /> Application Accepted by i�= Date <br /> �_ — ► ; f7 11,2 ND <br /> Pit or Grout Inspection by D Fin-al Inspection_by- - �� Date <br /> Additionat Comrrwnts: <br /> } <br /> Applicant - Return all copies to: baa Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hauiton Ave., P Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> pqj) 00 <br /> . EM 13-24(REV.rins> <br /> FHA-25 41 <br />