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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 0 BOR 2009, STOCKTON, CA 95201 ; <br /> -PERMIT 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health�Services.j 1 <br /> Job Address LI r�1rGl Yi d e c) City 40d !, Lot Size/Acreage Za 3 <br /> Owner's Name I ["U Ge 14 e,ttele _so Addressq � � y Lga Vt d G I 111:d_ _ __ Phone <br /> Contractor VageAddress r r>�09� �� of[ Y License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT $DESTRUCTION Out of Service well ❑ <br /> _w PUMP INSTALLATION O SYSTEM REP�IR ❑ � OTHER O—Monitoring L� <br /> DISTANCE TO NEAREST: SEPTIC TANK­�� SEWER LINES e _ DISPOSAL FLO. PROP. LINE J.,2,ngg <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIO S S <br /> F1 Industrial I -WOP06 Bottom ❑ Manteca Dia- of Well Excavation J Dia. of Wail Casing <br /> Cl Domestic/Private x Cl Gravel Pack CJ: Ca <br /> Tracy ; Type of sing--- �r1O / Specifications <br /> I'I Public r other n Delta ,`:Depth of Grout Seal r Typ"f out k gext <br /> >e rigation 3C.[t:lAppiox. Depth ''t I Eastern N` ySurface Seal Installed by &I &` f !%3 <br /> r Repair Work Done 0. Type of Pump t- �{H.P. --t 4 State Work Done <br /> Well DestructionWell Diame'te'r '� Sealing Material & Depth �ut.s <br /> - <br /> ^Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I ;DESTRUCTION I i lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth } <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines f Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> 1 t r <br /> SEEPAGE PITS 11 Depth Size ! Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line > <br /> DISPOSAL PONDS ❑ <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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting 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 taws of California." i <br /> The applicant must call for all required inspections. 6omplete drawing on reverse side. <br /> t t 1 <br /> Sign,e ,. Title: 7<C_G ZTJ2.e S _ Date: <br /> 1it <br /> FOR DEPARTMENT-USE ONLY l <br /> Application Accepted by Date f Ar <br /> Pit or rut Inspection by)7J P,14, DateL -- Final Inspection by Date : <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquln ounty Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT RUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT' 0. ' <br /> i <br /> . EH 13.24(REV,1ix5( Com. ''� t . <br /> _ EH 1426 `] <br /> i <br />