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" APPLICATION FOR PERMIT <br /> 3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ggMIT MIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made iito 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. <br /> Job Address WfMw City Lot Size/Acreage <br /> Owner's Name m r�'t��� - Address <br /> Phone <br /> Contractor 6y� I� , ' R.� Addresl\s IP4J3 X �j ���`+*�+o�-�� License No. Phone' <br /> TYPE FF—WELL/PUMP: I�;` NEW WELL © WELL REPLACEMENT 0 DESTRUCTION Cl out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1) OTHER © Monitoring Well fJ <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 /> f7 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia of Well Casing <br /> Specifications <br /> ['.I Domestic/Private� ❑ Gravel Pack ❑ Tracy Type of Casing <br /> I"1 Public v� t�.i.1 Oher Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> I I lrnivation �, 1�4pprox• Depth EI I Eastern Surface Seal installed by <br /> Repair Work Done'-,O r Type!of Pump H.P. State Work Done _. <br /> Well.Destruction ~❑ Weli'Diameter Sealing Material & Depth <br /> Filler Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-L Commercial—1 /Other d <br /> Number of living units: Number of bedrooms <br /> Character of soil to a_deptti'of 3 feet: l Water table depth <br /> �� ;iw <br /> SEPTIC TANK �R' t Type/Mfg 4 ` 4-1 Capacity Z•00" No. Compartments i <br /> PKG. TREATMENT PLT, 0 1 ` Method of Disposal <br /> 1 fDistance nearest: Well ��b Foundation �� Property Line— <br /> F `1070 <br /> LEACHING LINE � No. & Length of lines � Total len 9 <br /> th/size <br /> FILTER BED 0 Dlistance to nearest: Well_, � Foundations Property Line_ p� <br /> SEEPAGE PITS F�I I" Depth'" Sire Number <br /> 11 <br /> SUMPS Ll Dlistance to nearest: r' Well Foundation Property Line <br /> DISPOSAL PONDS : ❑ I _ <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 Sari Joaquin County <br /> Home owner or licensed agents 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 /> 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." _ l <br /> The applicant mu all for all requir d inspections. Com/plate drawing on reverse side. C��p <br /> Signed X - Y t Title: Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted-by ' Date Arei i <br /> r <br /> ! Pit or Grout Inspection by, -��' Date Final Inspection by Date <br /> AdditionalComments: """ 1 —�` cs n <br /> Applicant - Return all copies to: San Joaquin C unty Public Health I <br /> l Services, Eaviz'onmental Health Permit/Services <br /> Ali ! 1601 E. Hazelton-Ave., P 0 Box 2009, Stockton, CA 95201 <br /> r <br /> r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. i <br /> I INFO <br /> EN 13-24IREV.i/Kos I� .i/+� ,s- <br /> EH 3420 <br />