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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, ST'OCKTON, CA 95201 ff <br /> PERMIT EXPIRES 1 YEAR FROM DATXLISSUED1 <br /> 2-7 9 �,7_Q (--o—n..- Gf . (Complete in Triplicate) <br /> Application is hereby made to San Joaquin Count fora �ZZ — <br /> application is made in compliance with San Joaquin countyrOrdinance nNoru549$and ol$62satrd the eRules and work eRegulations in dof Sans <br /> Joaquin County Public Health Services. <br /> Job Address ,2_3 7QJUf 4'!r 9� __� <br /> City r� of Size/Acreage <br /> Owner's Name Phone 7 <br /> Contractor / C�rD �jC tu�Iq�AddTess <br /> _�'d_�� ��,3�License No. !' 170 Phone. <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT Cl DESTRUCTIO t of Service Weil ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well [7 <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 /> I I Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i I Domestic/l nvate 0 Gravel Pack LJ Tracy Type of Casing Specifications �) <br /> Il Public Ll Other fI Delta Depth of Grout Seal Type of Grout <br /> I I Initiation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done tJ Type of Pump H.P. St Work Done _ <br /> Welt Destruction 0 Well Diameter Sealing Material & Dept //( <br /> Depth Filler Material & De h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DES RUCTION (Na apt c system permitted if public sewer is <br /> avail blelwithin 200 Ieet.l <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 4 <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE L.I No. & Length of lines _ Total length/size ' <br /> FILTER BED I-1 Distance to nearest: Well�_ Foundation Property Line <br /> SEEPAGE PITS i I Depth _ Sixe Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I ha,eby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Hone owner or licensed agent's signature canities the following: "1 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 /> cartities 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 applican all require ' ".ctions. Complete drawing on reverse side. <br /> Signed % ' ���'` Title '�'s'��G /1 <br /> _.. Date: _. <br /> i <br /> OR Of=PARTMENT USE ONLY <br /> Application Accepted by ✓ Data © Area _ <br /> r <br /> f Pit or Grout Inspection by Date Final inspection by Date r f _ <br /> I <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NQ. <br /> INFO CASA <br /> 01 13 24 �t� „�b; too <br /> Er � 0� g b <br />