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APPLICATION FOR PERMIT <br /> SAN JOAQUIN_COUNTY PUBLIC HEALTH SERVICES <br /> y - ENVIRON1dENTAL HEALTH DIVISION � <br /> 1601 E. HAZELTON'AVE. , PHONE (209)468-3420 <br /> [J ! y <br /> +r P O BOX 2009; STOCKTON, CA 95201 / �J <br /> DtZRYI'1' EXPIRES 1 YEAR FROM DATE ISS[1ED <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 Ban Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San $ <br /> Joaquin County Public Health Services. i <br /> Job Address <br /> �4 / City Lot Size/Acreage <br /> + � l <br /> . Q,� Phone <br /> ,{ ,� l V <br /> A C��d-Y TU G► l Address `Owner's Name CS, <br /> 7 <br /> O7 j 2J7 <br /> �00 ­5 <br /> LicenseNo. !j L Phone Addressrvice Wel Contracto �� _ t.of Ser 1 <br /> TYPE OF WELL/PUMP: ' "'ry. NEW WELL ❑ WELL REPLACEMENT f� DESTRUCTION L7 Monitoring Well ,. <br /> `PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR i OTHER ❑ <br /> DISTANCE TO NEAREST:` SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Industrial -f] Open Bottom ❑ Manteca pia. of Well Excavation Specifications <br /> Gtpomestic/Private '❑ Gravel Pack ❑.Tracy^ Type of Casing <br /> (Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> Il Public , <br /> t I Irrigation �� .Approx. Depth I 1 Eastern Surface Seal Installed by C <br /> H•P• State Work Dona <br /> Repair:Work Done th :Type of Pump +s��— "Sealing g Material & Depth <br /> Well Destruction .O ,Well Diameter Filler Material b Aepth <br /> Depth <br /> Y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I (No septic systethin m r iitted if public sewer is <br /> availab" Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. 3-•«Type/Mf" Capacity No. Compartments <br /> PKG. TREATMENT PLT. Ll :� i Method of Disposal <br /> �. <br /> -Distance,to nearest .. Well Foundation Property Line <br /> LEACHING LINE Ll +No. & Length of lines Total length/size � <br /> FILTER BED CI 'Distance to nearest: _.Well Foundation Properly Line <br /> I <br /> Number <br /> SEEPAGE PITS /' I I Depth. Size <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line �. <br /> DISPOSAL PONDSstate taws, and <br /> , "❑ "'�"" �+°r <br /> I hereby certify that I"have-p_ repared-this-application-and.that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations'6t4fie 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, l shall not <br /> employ any person in" nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature �- <br /> c�rtifies the folio g:;'I cacti .thai in the perfo ante t s work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of C otnia:" 1 •.Lg <br /> The applican mus call 1 ' requir i to rawing o rev side. <br /> I `~ ✓ <br /> Signed _ <br /> Title: Date: <br /> :;. FOR DEPARTMENT USE ONLY <br /> c� /C_p.��• -- Date Area <br /> Application Accepted by �.�,.. - � <br /> k Pit dr Grout Inspection by Date ! :r "-Final"Inspection by-i ate <br /> -�-J--Additlorial Comh+infi: <br /> Applicant - Return 812 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 CK RECEIVED BY DATE PERMIT"NO. <br /> IEEE 11ALLMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24 IREY,It n 5) 7� �� O �" �... <br /> Eli 11.26 <br />