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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 0 BO%'`2009, STOCKTON, CA 95201 <br /> PERKIT 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> -. L- ► tom -ti ttl/ T of Size/Acreage �S 17_ <br /> Job Address Q Q It�y_,t <br /> Owner's Namey"4e'�Cre M rQ-R-Tc..�� �� Addressy 1 u E•+- +1er-{ f" - Phone 0 2-1 <br /> Contractor �- �`^ Address License No. Phone 0 <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS [TI <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'1 Public I 1 Other n Delta Depth of Grout Seal Type of Grout <br /> i I Irdoation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth Filler Material & Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 4"o Commercial— Other <br /> Number of living units: _-I— Number of bedrooms Zm / <br /> Character of soil to a depth of 3 feet: 1-0 r4 4.1 . Water table depth <br /> SEPTIC TANK [Type/Mfg P-'h ck-_sG)P� Capacity r No. Compartments L <br /> PKG. TREATMENT PLT. ❑ r Method of D-��?ll fr�r�/' De-P. <br /> Distance to nearest: Well a Foundation Ls Property Line <br /> LEACHING LINE 0 No. & Length of lines Totfl length/size <br /> FILTER BEDS Distance to nearest: Well Q_ _ Foundation _U 2: Property Property Line r <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 1:7 <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 /> The applicant must II for all required 1P ctions. Complete d wing on reverse side. <br /> Signed Per Title: ,_,W Date: �� d <br /> F DEP MENT USE ONLY / <br /> Application Accepted by Date Area � <br /> Pit or Grout Inspection by Date Final Inspection by Da�. <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-21 MCV,t/A SI S �-5 `'� <br /> EH il•26 1 C7 XS o d CJ <br />