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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! i <br /> ENVIRONMENTAL HEALTH DIVISION ; I <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County fora 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 Healthices <br /> Q i <br /> Job Address U� City Lot Size/Acreage <br /> Owner's Name' "' Address AV,�21 - Phone <br /> 40. <br /> Contract c Address 1-. D 40>( 74 License No z9�Z� Phon �O`�Jl� <br /> le <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> .y - _ f.-. --.- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> =7 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public El Other n Delta Depth of Grout Seal Type of Grout r? j <br /> I I Irrigation Approx. Depth. I I Eastern, Surface Seal Installed by. V- <br /> r� f <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Wait Destruction ❑ Well Diameter \ Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I IR AIR/ DDITIO DESTRUCTION 1. 1 (No septic system permitted if public sewer is <br /> / available within 200 feet.I <br /> Installation will serve: Residence r Commercial Other. <br /> Number of living snits: Number of room �2 I <br /> Character of soil to a depth of 3 feet: — _ r Water table depth e <br /> SEPTIC TANK. �❑ Type/Mfg € Capacity ^No. Compartments <br /> PKG. TREATMENT PLT. C7:�, t ' Method of Disposal <br /> 1,j Distance to nearest: I Well Foundation Property Line k , <br /> LEACHING-LINE N: A Length of lines `4 - Total length/size <br /> FILTER BED E) 'Distance to nearest: Well s:m Foundation Property Line_ �5_ _! 1 <br /> SEEPAGE?FITS, yX Depth Site Number _ <br /> SUMPS -" Ul Distance to nearest: _ Well t`"` Foundation _ Property Line <br /> DISPOSAU-PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance Wah''San'Joaquin county ordinancesr state laws, and <br /> rules and regulations of the San Joatluin County �, `• <br /> Home owner or licensed agent's sign`afure certifies the following: "I certify that in the performance of.Via work�for which this permit is issued, I shall not <br /> employ any person in such manner as to becoemsubject`to-workman;s-compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in theperformance of the work for which this permit-is issued, I'shall•enipldy persons subject to workman's compensa- <br /> tion laws of California." f 0 <br /> The applicant t call for all irenspections. Complete drawing on reverse side ti <br /> i N O l I <br /> Signed �- ,Title:- r Date: t , <br /> ,: FOR DEP"ATMENT USE ONLY �} l' <br /> Application Accepted By vDate Area l� <br /> a S ; <br /> /PiYor Grout Inspection by at Final Inspection by � Date k <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> it <br /> Services, Environmental Health Permit/Services � I <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK I i <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + Eli 13.2 (REV.I)n sl00 <br /> EH i42a 1 W [ L <br />