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APPLICATION FOR PERMIT <br /> SARI JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMBNTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I Imo{ IT EMIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or insta.11 the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of,San <br /> Joaquin County Public Health Services. _ /YD0 L <br /> Job Address 7 �/ 7+/` City��eA'I117t Size/Acreage <br /> Owner's Name Ci71 Address c�_13 OPhone <br /> f Contractor Address6 `y� �d f; T License ND.o�/d'Cd� Phone <br /> 1 TYPE OF WELL/PUMP; NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION [- Out of Service Nell <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> { DISTANCE TO NEAREST: SEPTIC"TANK' SEWER LINES DISPOSAL FLO. PROP. LINE <br /> ' FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS _ <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCTIDN SPECIFICATIONS <br /> 71 Industrial O;Open Bottom n Manteca` Dia.,of Well Excavation Oia. of Well Casing ` <br /> M Domestic/Private C1 Gravel Pack O Tracy ? t Type of.Casing-_ Specifications e,'\ <br /> (1 Public 171 Other (-1 Delta 060th of Grout Seal Type of Grout <br /> I I hrigation _ Approx. Depth 11 EasternSuiface Sbal Installed by <br /> Repair Work Done LJ Type of Pump - X.P. ..t ,y State Work Done._ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth t Filler Material b_Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R I REPAIR/ADDITION DESTRUCTION I I lNo septic system permitted if public sewer is + <br /> S available within 200 feet) <br /> Installation will serve:- Residence_ Commercial_ Other _Ip <br /> Number of living units: Number of bed ooms <br /> Character of soil to a depth of 3 feet: n _ r- Water table depth <br /> SEPTIC TANK D T /Mi <br /> , yPe g � L Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cly% Method of Disposal <br /> L Distance to nearest: Well Foundation'= Property Line <br /> L <br /> LEACHING LINE � No. & Length of lines.. �r � Total length/size ��— <br /> FILTER BED 11 Distance to nearast: Well Icx�4 oundatwn � Property Line <br /> - rh <br /> SEEPAGE PITS 1 I ��` <br /> Depth Size f' -_ Number <br /> SUMPS Q( Distance to nearest: Well 4F Fo_undation 109 F 7—Propeny.Lin6_ 5d iF'r— <br /> DISPOSAL PONDS 0 <br /> i hereby.certify-thal-l.have-prepared this,applicatlon and that the work will be.done in.accordance with county ordinances,.state laws, and <br /> rules and reguiations of the San Joaquin County % . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance-of-ihe 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 pr sub contracting signature <br /> certifies the fallowing: "I certify that in the performance of the work for which this permit is issued;J shall employ persons subject to workman's compensa- <br /> tion laws of California." ' e - t -- <br /> The applicant must call f r an r fired inspections. Complete drawing on reverse side. r <br /> Signed X � ��C,. Title: _1'`-•-Z- � ` -� pate: <br /> FOR DEPARTMENT USE ONLY <br /> Appllcetion Accepted:byDatePit or Grout Inspectioy Date Final Inspection bl= c�+� _/ � �.Date 6 <br /> Additional comments: <br /> Applicant - Return all 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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMITNO. <br /> EM 14.7,IHEY. �. <br /> EH 1fQe n ll l- l�/ <br /> K ' <br />