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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heresy 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 9 yt� ��ANA ST - CitY �t Lot Size/Acreage <br /> OwnerPhone's Name • ' ��x Address ,"� C 3 —LYr-f <br /> Contractor l (�� Glg�-C s Address'"V �Qy 1717 License No3773�r Phone3y-y7' <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTtON Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 10 DISPOSAL FLD. PROP. LINE lS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> )WDomestic/Private >0 Gravel Pack 0 Tracy Type of Casing 0A'-<_ _ -_-- Specifications <br /> 0 <br /> ['I Public [:1 Other n Delta Depth of Grout Seal _/yc7 T <br /> p Type of Grout <br /> I I lrrigation ( P60 Approx. Depth I I Eastern Surface Soul Installed by C.a&�i� --25r— -- <br /> Repair Work Done L] Type of Pump sU H.P. Z State Work Done <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 INo 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 Q <br /> r ; <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments ^'/} <br /> PKG. TREATMENT PLT;❑ - - Method of Disposal �L J <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 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 /> amploy any person in such manner as to became 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 ainploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all r uired inspections. Complete drawing on reverse side. <br /> Signed X Title: l <br /> Date: C Z L�— <br /> OR MENT USE ONLY-- <br /> r` <br /> Application Accepted by r nate,5 Area <br /> Pit o G <br /> ,l spection hyl Date3 Final Inspection b>f� Date3 <br /> Additional Comments: �Wj � <br /> Applicant _ Return all copies to: San Joaquin County I t Hea -bi 1 <br /> Services, Environmental Health Permit/Services/ <br /> 1601 E. Razeltoa.Ave., ]? 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE Q j PERMIT'NO. <br /> + EK 13-24 REv.rinse aV' `� ll <br /> 4 <br />