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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, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE JaSURDD <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. p / <br /> Job Address r; 3 � (v I=erC K n 1 r!� !�—J _ _ City,-4-4NpLot Size/Acreage <br /> Owner's Name Address<>aC'Yi 1 k I J-1 C� .L=S!_ Phona <br /> ontractor vd-.Ile_ >1 A AddressPPQ+ � 2{� License Nr1 �9��G�__Phon Q 7 <br /> YPE OF WELL/PUMP: NEW WELI-LIX WELL REPLACEMENT ❑ DESTRUCTION ❑ Dut of Service Well ❑ <br /> r U <br /> (STANCE TO NEAREST: SEPTIC TANK ?= / SEWER LINES DISPOSAL FLD. PROP. LINE/� j <br /> OUN ATI N AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE fiWov, L PROBLEM AREA CONSTRUCTION SPECIFICATI NS J�(} r� <br /> Industrial Open Bot ❑ Manteca Dia. of Well Excavation Di Wel Casing <br /> Domestic/Private 0 Gravel Pa ❑ Tracy Type of Ca�' ia� Specificatt s <br /> I Public i-1 9"r F1 Delta Depth of GZt0eal Type of Grout J e <br /> I Irrigation _Approx. Depth 1 1 Eastern jSurf ca Seal Installe ` f <br /> spair Work Done 0 T pe o Pump H.P. Stat pppe Y <br /> ell Destruction ❑ e!! Rt4Ura Sealing Material & Depth <br /> pth Filler Material & Depth —1 <br /> YPE OF SEPTIC WORK: I 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer i �J <br /> available within 200 lest.► <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living_units: Number bedrooms <br /> Character of soil to a depth of 3 feet: ______ ___-_ __ __ __- Water table depth <br /> V1 EPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments <br /> VJ KG. TREATMENT PLT. ❑ 0J Method of Disposal <br /> A °?rW.o ne rest I Foundation Property Line <br /> V ACHING LINE Cl No. & Length f lines Total length/size <br /> ITER BED ❑ Distance to nearest. Well Foundation Property Line <br /> EEPAGE PITS 11 Depth Size _ Numb f <br /> MPS Ll Distance to nearest: Well Foundation Prop,14 00 <br /> ISPOSAL PONDS 0 v <br /> Ihereby 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 /> r iles and regulations of the San Joaquin County <br /> ome 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 she 1 not <br /> e nploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sigr 3ture <br /> e irtifies 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 comp nsa- <br /> t n laws of California." <br /> gne Title: Ie Date: <br /> F R PARTMENT USE ONLY f� <br /> plication Accepted by Date b `� Area <br /> P i or Grout Inspection Eby `�, Dat -!s IG-__ Final Inspection b C> Dat ~ f �� <br /> A ditionai Comments: Y I p <br /> A>pllcant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> *60! 2. ftzetttm ., <br /> FEE INFO AMOUNT DUE AMO NT REMITTED CA Rf�L`� 4�/J� DATE PY�EIRMI7'NO. <br /> . EH 13-24(REV.1/N 5F <br /> EH,4.26 /co <br />