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:. <br /> f 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 BOX 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. {y /{pLF6K) <br /> Job Address City <br /> Z'S'1S �ro.c Bo--.�.gVrx1 �CrwG Lot Size/Acreage ( 5r1d) 7�y -Sf3`j <br /> Y _ - <br /> Owner's Name F�a ` CO Address 3$00 ice., Phone (212) <br /> C M <br /> O <br /> Contractotw`.-,�- u°`x' "`} Address Zia ger iLov...License No.SS'�l _ Phon <br /> TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER O Monitoring Well<. <br /> ry 1.�s11 <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 CONSTRUCTION SPECIFICATIONS <br /> r� <br /> n industrial O Open Bottom C Manteca Dia. of Well Excavation f2'r Dia. of Well Casing �� <br /> J<bomestic/Private WGravel Pack CWTracy Type of Casing ?VC. Specifications <br /> I'1 Public I"1 Other fl Delta Depth of Grout Seal _ Y� Type of Grout 40-k+ <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by L.'res 4 MLZV---,4- <br /> Repair Work Done C3 Type of Pump - H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth L <br /> Depth Filler Material 3 Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size .Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 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 /> The applicant must call for all required i ctions. Complete drawing on reverse side. / <br /> Signe ` Title: -4 �k �1� S`� Date: ITJ -- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate ItIl Al Area �� - <br /> Pit or Grout Inspection by Date Final Inspection by c Date <br /> Additional Comments: S <br /> f. <br /> Applicant - Return all copies to: San Joaquin County Public Health C� Lido <br /> Services, Environmental Health Permit/Services 7 <br /> 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201FEE <br /> )NEO AMOUNT DUE AMOUNT REMITTED CASH BECEiVED BY DATE PERMIT'NO. <br /> • EEM 3-24 <br /> li 11.70 IHEv.IiMSI 00 co 7 33ti �Yl� ti 1- l35 <br />