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i <br /> -. APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f <br /> ENVIRONMENTAL HEALTH -DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1_YEAR-FROM DATE $LXX) <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 City OAI,141Lot Size/Acreage l_J <br /> Owner's Name ,LfJC/1-htNt Address Phone .' <br /> `r r ! V0 2 , P �O S/W <br /> Contfac resfO. <br /> or <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION CI Out of Service Well ❑ 4'! <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS r, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing (� <br /> C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public I1 Other F7 Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done V <br /> Well Destruction O Well Diameter Sealing Material-&-Depth <br /> i ti <br /> Depth ler Material-& Dipth1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l IQ EPAIRI DITIONX 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 ooms .Y <br /> Character of sail to a depth of 3 (us tiA-f- 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments:_ (� <br /> PKG. TREATMENT PLT. ❑ Y +� :•t __v �' r,=. Method of Disposal 4 !!! <br /> Distance to nearest: Well) Foundation `Property Line a <br /> LEACHING LINE >< No. & Length of lines — �, Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 1Q-- Foundation >O Property Line c:- <br /> .. <br /> SEEPAGE PITS Depth Size ," Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line Tt 2�— <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 �l <br /> rules and regulations of the San Joaquin County `A <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 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,�l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Theapplicant m11 for all quirad inspections3 Complete drawing on revers da. <br /> Signed Tithe: -V��� Pate: <br /> 9� <br /> 9 � <br /> �A FOR DEPARTMENT USE ONLY <br /> l�l <br /> Area <br /> Application Accepted by _.��/ Date / i <br /> or Grout Inspection by j ate Final Inspection by Date <br /> F � <br /> a <br /> Additional Comments; t ! <br /> Applicant - Return all copies to: San Joaquin County Public Health .I <br /> Services, Environmental Health Permit/Services � <br /> 1601 B. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK i RECEIVED BY BATE PERM17•NO. <br /> INFO CASH <br /> ♦ <br /> 1H3'24 IREV.11 x 5l (�- , ILA D <br /> EH i4.2e l CS <br />