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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)488-3420 <br /> P O BOX 2009, STOCSTON, _CA 95201 <br /> E%P RES 1 YEAR FRQM PATE ISSUBP <br /> (Complete in Triplicate) <br /> 0 <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 AddressI�g City —O Lot Size/Acreage <br /> -v-"�� <br /> Owner's Name Address y 7 dW Z0271 n1 Phone <br /> r Contractor ) I '► I Address T• •t�c�s`+� �' 'License.No.o2��3S� Phone <br /> TYPE Of WELL/PUMP. A NEW WELL O- T WELL REPLACEMENT - 'DESTRUCTION-0 out,bf,Serviee Well❑ <br /> PUMP INSTALLATION O,. SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> d <br /> DISTANCE TO NEAREST: SEPTIC TANK 10, SEWER LINES DISPOSAL FLD, PROP. LINE <br /> f <br /> FOUNDATION--- -AGRICULTURE WELL OTHER WELL/—,--;' PITSISUMPS <br /> INTENDED USE TYPE OF WELL,. PROBLEM AREA CONSTRUCTION SPECIFICAT12NS <br /> n Industrial fQ Open Bottom C] Manteca i Dia_ of Well Excavation; Dia. of Well Casing 1 �Y <br /> Domestic/Private ❑ Gravel Pack -❑_Tracy__) -Type,of Casing Specifications <br /> P blit I.) Other n,Deltat --Depth'ot'Grout Seal /Tyne f Grout�3 �� rtt ` <br /> rigation � .^� y L Approx. Depth . I i Eastern Surface Seal Installed by Q. l <br /> epair`Work Done 0, Type_of-Pump :H.P.t State Work Done <br /> } Sealing Material & Depth P' <br /> Well'Destruction O Well Diameter ; <br /> J!.0 Depth' Filler Material & Depth s (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION 1 1 DESTRUCTION I I lNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> 'Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> i <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. 0 Method of Disposal <br /> C4 Distance to nearest: Well Foundation Property Line 4 <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> rulesAnd regulations of the San Joaquin County , <br /> Home owner or licensed agent's signature cenifies 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." 1 <br /> The applicant must call for all required insPections. Complete drawing on reverse side. <br /> Signe X Title: ��`'lDat <br /> yy f�-��� <br /> __ __ _----- e: <br /> f <br /> FOR DEPARTMENT USE ONLY_ <br /> Application Accepted by Date Area <br /> Pit or,rirCjt Inspection by Date Final Inspection by Date ` <br /> Additional Comments: - <br /> r Applicant - Return all copies to: San Joaquin County Public Health <br /> i Services, Environmental Health Permit/Services <br /> 1601 E. Hat;elton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> s FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'No. <br /> } INFO CASH 1 .y! <br /> I . EHt32401EV.il�51 <br /> EH 14.26 <br /> l <br />