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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br />{ <br /> P O BOX 2009, STOCKTON, CA 95201. � } <br /> IIPERMIT 9XPIRES 1 YEAR FRQJM DATE ISQUED <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 ls'made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �} Lf <br /> Job Address � �o �t34_[1!� j- fi� City-Vcff ey- 7tw. - -t Size/Acreage <br /> Owner's Name cc, 10 " Address c f Phone <br /> Contractorlb4 It I C Address License W Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,,,,,DESTRUCTION ❑ Out of Service Well ❑ c <br /> ` PUMP INSTALLATION ❑ SYSTEM REPAIR© OTHER ❑ Monitoring Well C3 <br /> pr DISTANCE TO NEAREST: SEPTIC TANK ';" ' SEWER LINES r DISPOSAL FLD. PROP. LINE <br /> E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial �, Cl Open Bottom © Manteca Dia. of Wall Excavation Dia. of Well Casing <br /> I + 1 . <br /> Ca Domestic/Private"-D GrBvei Pack -0 Tracy Type of Casing L Specifications <br /> I'I Public i.1 Other I-1 Delta Depth of Grout Seal Type of Grout <br /> i I lrri0ation .Approx. Depth„r„I_"j,Eastern Surface Seal Installed by <br /> Repair Work Done U Type"of Pump H.P. State Work Done <br /> R Well Destruction D Well Diameter Sealing Material Depth <br /> 4 <br /> ! Depth Willer Material 8 Depth- <br /> -TYPE <br /> epth TYPE OF SEPTIC WORK: NEW INSTAL ION! 1 REPAIR/ADDITIONK DESTRUCTION I I INo septic system permitted if public sewer is �V <br /> available within 200 feet.! <br /> Installation will serve: Residence T Commercial _ Other <br /> } �'Number of living units: Number of bedrooms <br /> Character of soil to a depth o6 3 feet: y 4 <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines O Total length/size <br /> FILTER BED i [7 Distance to nearest: Weil = Foundation Property Line�-_ <br /> R- <br /> SEEPAGE PITS ql i Depth Site t Number <br /> SUMPS .y'; ,._n x�. <br /> LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C1 <br /> I hereby certify that I have prepared this application and that the work will be dohe-ir accordance with San Joaquin county ordinances; state laws, and <br /> rules and regulations of-the San Joaquin County' i <br /> 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 y <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 workm n's compensa- <br /> tion laws of California." R <br /> The applicant Must call for all r uire inspections. Complete drawing on reverse side. r <br /> �1 <br /> Signed Date: <br /> e� <br /> OR D RTM USE ONLY <br /> Application Accepted by R "r Date o A a <br /> Pit or Grout Inspection by bate Final Inspection b Date ' <br /> Additional Comments: <br /> t Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental HealthrPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ♦ EM13-24(REV.1/N51 1Q/ <br /> �IE !4—­J <br /> fH 7 <br /> 2 k <br />