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f o 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 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIREg ]. YEAR FROM FSD <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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health/Services. *-� <br /> Job Address .� ,V ���^ [Grp _ ------- City tot Size/Acreage � 2,0 Qc ---- <br /> Owner's NameAddress 7be_k L)&f &L Phone -1 <br /> Contractor L&11yfkJ 40614haAddress PL/,I]a n2 45pdt ly. _License No 2g93S3 Phone e? <br /> -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT - - DESTRUCTt -Out-of-Servi-ce•Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 <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 3 <br /> n Industrial Open Bottom D Manteca Dis. of Well Excavation `69 Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ��t�! � Specifications <br /> 11 Public Cl Other n Delta Depth of Grout Seal -5-40/ Type at rou�C�ew�9S . <br /> �I"Irrigation *00-- Approx. Depth I I Eastern Surface Seal Installed by ,I/d rY <br /> Repair Work Done L3 Type of Pump , .� H.P. tate Work Don <br /> Well Destruction X Well Diameter Sealing Material & Depth :'weft <br /> Depth 14 j : Filler Material & Depth � .3irl"iKA _ <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet.► f <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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> X <br /> SEEPAGE'PITS I I 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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F <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." { <br /> The applicant must call for all required inspections. Complete drawing on reverse side. r <br /> Signed 2 4 42V S e: - ec &Jle -- ___ Date: aa' <br /> Oft DEPARTMENT USE ONLY <br /> Application ccepted byDate _ ��"-\—,"t' Area <br /> Pit r rout I pection by Da� i.-�� t Final Inspection by Dale TL�YL <br /> Additio Comments: <br /> Applicant - Return all copies to: San Joaquin County PublicHealth <br /> Services, Environmental Health rtnit/Services <br /> • 1601 E. Hazelton Ave., P 0 B x 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE f yPERMIT NO. <br /> EH 14 (REV. ksl Q, .� ! i . -1 <br />