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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEWIT 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 Services. <br /> Job Address `' CAk(o` kt City Lai Lot Size/Acreage I QGfG <br /> Owner's Name t ArxkW IAL AddressQ-6 +)`Tk1.�5�` k r� _ � 30 Phone -0?-41 { <br /> �y�d 3 Ft{zycreAk ko&� <br /> Contractortrtl� & - _._Address qS License No. S Phorer�tD <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION X Out of Service Well Cl <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER Q 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 /> C1 Industrial O Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E.l Domestic/Private 0 Gravel Pack C1 Tracy Type of Casing Specifications <br /> Fl Public 1-1 Other z I1 Delta Depth of Grout Seal Type of Grout -42 <br /> t I Irrigation —Approx.;Depth I I Eastern Surface Seat installed by <br /> Repair Work Done L] Type of Pump Hop. S to Work Done <br /> Well Destruction "A Well Diameter I�tt� Sealing Material 3 Depth r �� 1 <br /> �i.Wr✓[�S Depth 60 -Fat'_{' Filler Material 8 Depth AS ,669VL - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence'I 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 D Type/Mfg{ Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1 i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS If Depth f Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CJ <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 <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 /> J The applicant griusstt call forallrreefg44red inspections. Complete drawing on <br /> I reverse side' <br /> Signed X Title: 4�9e4r Jl/7k C�'Afl, O <br /> S_ Date: Z Ct <br /> U FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z q Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> "AA-) <br /> MW <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 Dt1E AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> CK <br /> INFO h *C <br /> . EH 13-24iREV.1/x5V ���b 6 i7y <br /> EH i42s 11VV <br />