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.In <br /> V 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 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 /> i <br /> Job Address r­�0o0 X-sso City 10 Lot Size/Acreage <br /> r^ > Ld -8sC, <br /> Owner's Name ° l�y�r/-'1 kF� !7 Address [J /¢ Phone <br /> Contractor -� 1 Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WCEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ REPAIR ❑ OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER\L / DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T pe of Casing Specifications <br /> I'I Public 1-1 Other n Delta De th of as <br /> Seal Type of Grout <br /> I I Irrigation Approx. Depth 1 1 Eas rn Su ce Seal Installed by C� <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Mate al & Depth <br /> Depth Filler Materia 6 Depth C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I. REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is Q <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other �-Lvv VSA <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK O Type/Mfg , Capacity ' O�'Sava No. Compartments Z <br /> PKG. TREATMENT PLT, O 60t Method of Disposal <br /> Distance to nearest: Well ��// Foundation Property Line <br /> LEACHING LINE IM No. & Length of lines 7a Total length/siz 6 v <br /> FILTER BED Distance to nearest: Well 'e Foundation Property Line t "nom <br /> i"16 t! f <br /> SEEPAGE PITS I I Depth Size r�INumber <br /> SUMPS Distance to nearest: Well O J Foundati C� Property Line ~ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this ap . tion 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 <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 applic;��or all req gyred inspections. Complete drawing o reverse side. <br /> rSigned Xy,i ?�� Title: Date: <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by � � C( AAIC--c&moi„ Date -3�a�� Area �— <br /> Pit or Grout Inspection by Date Final Inspection by4­� <br /> Dateo <br /> Additional Comments: -� � /_/ <br /> Applicant - Return all copies to: San Joaquin County Public Health 14 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE c, PERMI7*NO. <br /> EM 13.21(REV.1/"5) (� �/�)C1 - D yU t� <br /> EH 24.2a <br />