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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PC3BLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br />�I <br /> 4PERMIT EXPIRES 1 YEAR FROM DATE ISSUEP t <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;vith San Joaquin County Ordinance No. 549 and 62 and the Rules and Regulations of San <br /> Joaquin County Public <br /> ccSfHeealth Ser ices. <br /> Job Address v 2— . C9-icns <br /> Lot Size/Acreage <br /> Owner's Name "' ` Address_ Phone <br /> ff ,�-J—Confrac - - - lo. Phone_- _2_ <br /> I TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well Lf <br /> PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER Q Monitoring 41e11 <br /> l DISTANCE TO NEAREST: SEPTIC TANK SEWER L{NE5 DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTUR WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> ' f7 Industrial ❑ Open Bottom ] Manteca Di - of Well Excavation Dia. of Well CasingVJ"`J <br /> FI DomesticIPrivate ❑ Gravel Pack ❑ racy_ __: T e of Casing Specifications <br /> f <br /> I'I Public f:1 Other # !� Delta D pth of Grout Seal Type of Grout <br /> I I Irrigation _ ApproJ Depth t I Eastern S nate Seal Installed by ' <br /> Repair Work Done ❑. Type of Pump H. State Work Done t <br /> " Baling Material 6 Depth <br /> Well Destruction O i Well Diameter <br /> 1. <br /> Depth 1 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION r REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is J <br /> VI , _ tv �- ,., A vailable/�^'sthin feet.l 1R <br /> y Installation will serve:,-Residence=L-^�-�Gomrnercia! Other (�t�[>0 /�, � RIF <br /> Number of living units: Number of bedrootlII�--- [J" " fr <br /> f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i SEPTIC TANK cU Type/Mfg Capacity I No. Compartments' <br /> f Di o <br /> t PKG. TREATMENT PLT. ❑i 4, , , A.� Method ',i spsal <br /> € ` Distance.(to nearest: Well N Foundation Property Line sr <br /> LEACHING LINE ❑. No'.&Length of lines t T }al length/size <br /> FILTER BED +'t❑ Distance to ntiarest; Well -�_ _ Foundation . Property Line <br /> SEEPAGE PITS I I Depth Size Mber <br /> SUMPS LI Distance to nes esti Well IVJOY-e Foundation, Property Line <br /> DISPOSAL PONDS El ! s �T. All <br /> f 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 /> i rules and regulations of the,San Joaquin County <br /> ' Home owner or licensed agent's signature certifies the following: 'kl 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 /> f 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 <br /> compensa-tion taws;of California." <br /> s The applicant ust call Mr equirad i peptions. Complete drawing on reverse side: t " <br /> Signed X Title: . Date: <br /> FO�RTM NT USE ONLY y f <br /> 5� <br /> Application Accept's by Date �' rea <br /> _ s <br /> A L� <br /> f Pit or Grout Inspection by Dater L inal Inspection by Date <br /> ' Additional Comments; I <br /> $ ---- <br /> Applicant - Return all copies to: San Joaquin County Public Heal <br /> 1 Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> .FEE* AMOUNT.DUJ' ""�. AMOUNT-REMITTEC- CK RECEIVEDf3Y' --DATE" - -'PEiiNtl7'NO. <br /> CASH_� <br /> EH 13.21(REV.ii x 55 + ��� ' tif4 1L �'^•C � 1 <br /> i EN 71-2e 1 VVff~~ <br /> t <br />