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APPLICATION FOR PERMIT II <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES lQ 10� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS5UM <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joa uin count for �7--0-0o <br /> 4 y 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. <br /> Job Address CaLAder City F40'Ml�gj Lot Size/Acreage Q qCre <br /> Owner's Name _ Address <br /> �p � Phone <br /> ContraCtor 104 MP Ply -5;_ <br /> P OQ' ��34 <br /> ` License No. 3 L -� Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ W <br /> PUMP INSTALLATION D SYSTEM REPAIR . OTHER C] Monitoring Well I7 W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-) industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 10 <br /> I'I Public I-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ,_._.,Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done gi <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 Ieet.I <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. ❑ Method at Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 'Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 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 bedonein 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." Contractor's hiring or sub-contracting signature <br /> cenifies 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 Califo <br /> The applica m call for all required inspeciio s. omplete drawing 9w r verse side. <br /> Signed? <br /> Date: — ~-2, ... �� <br /> EPARTME T USE ONLY <br /> Application Accepted by C.lah ! <br /> Date �i.� Area <br /> Pit or Grout Inspection by Date F' I Inspection b pa Z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Publicealth <br /> Services, Environmental He 6th Permit/Services <br /> P1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> r INFO FEE MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITN0, <br /> �' [� �]l <br /> + EH 141-32/tREV.+iw �• v L � �O �� �� *T1_7 l 9 r -A21 f <br />