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APPLICATION FOR PERMIT <br /> J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br />' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PFJWIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . 1 <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. / ` t <br /> Job Address ! �00 / 2 K+/1CW City 7V4C V Lot Size/Acreage <br /> A' <br /> s <br /> Owner's Name Address Phone <br /> - <br /> ContractorAddress ! l�{-� -Y� � ^= - License-1%1042� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C1SYSTEM REPAIR OOTHER ❑ Monitoring Well <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 /> * industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private r 0 Gravel Pack ❑ Tracy Type of Casing '' Specifications <br /> I"1 Public (-I Other �'I 1­1 Delta Depth af`GroutlSeal Typo of'Grout <br /> I I lrrigation _ApproJ Depth I I Eastern Surface Seal Installed by. <br /> .'_ <br /> Repair Work Done U Type of Pump 4- H7P' `^"•` -- —^State Work-Done ....:- <br /> Welt Destruction ❑ Well Diameter - sealing Material & Depth, <br /> Depth , Faler Materiel & Depth <br /> _ _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION t I lNo septic system permitted if public sewer is <br /> Ll available within 200 feet.) G <br /> Installation will serve: Residence!= Commercial -Other __ - Y <br /> � b <br /> Number of living units: -_ Number of bedrooms 4 r <br /> Character of soil to it depth of 3 feet: ) p Water table depth <br /> SEPTIC TANK n ❑ Type/Mfg _� � Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. C7 <br /> Method of Disposal <br /> i Distance to nearest; WelVGat Foundation Property Line <br /> LEACHING LINE No. & Length of lines �C ^�d Total length/size T <br /> FILTER BED n Distance to nearest: Watt j.4�7t' Foundation ! )Pro rlLine I FT S <br /> SEEPAGE PITS 11 Depth 11L916d Site J1 Number --__ _L Y i <br /> SUMPS Distance to nearest: Well ' ' Foundation�' Property Line r2 <br /> DISPOSAL PONDS ❑ <br /> E. <br /> I hereby certify that I have prepared this'application a70-t.laat_the_w.ork will_be done in accordance with San Joaquin county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin County' i I F <br /> Home owner or licensed agent's signature certiti6s the following: "I certify thatin-the-performance of the work for which this permit is issued, I shall not <br /> j 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 /> 1 cortifies the following:"I certify that in the performance of the work for which thii,jk'mit is°issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applicant must call for allquir d insPections. Complete drawing on reverse side. Gl <br /> Signed X Title: _._ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t Dale U ,Asea <br /> Pit or Grout Inspection bDate Final Inspection Date Z rt0 <br /> ..s ... 4 <br /> Additional Comments: l `X1_ <br /> Applicant - Return all copies to, San Joaquin County Public Health <br /> } Services, Environmental Health Permit/Services <br /> t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> -. -- - - <br /> ..� .- -INFO--a..AM_6U_hTDUJE ' ,,: M0UNj_REMITT.ED_.... ._� it ,,,,�„-RECEIV.ED-BY--»-� - - DATE PERMIT NOr --- ---- <br /> . EH 13.24(REV,I/as) <br /> CH 21.20 ZT, <br />