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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)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> j p"IT EXPIRES 1 YEAR R M DATE "ISSTT'D <br /> (Complete in Triplicate) <br /> Application is hereby made.to Sen 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 /> e <br /> Job Address 0 O City /rte Lot JSize/Acreage Q <br /> !!! 's Name � i le ddress Ib c71V l e -c <br /> !L Phon <br /> e 4b' <br /> Owneras, FU63 & <br /> ae <br /> +� Address - <br /> t� Contractor SGr 4- - _ -Su License No:! -_Phone r <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well <br /> toying 11 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER Rarw, Q <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 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 /> n Industrial 0 Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> C7 Domestic/Private Ll Gravel Pack 0 Tracy Type of Casing Specifications I <br /> I'I Public fa Other n Delta Depth of Grout Seal Type of Grout I <br /> ik I I Irrigation Approx)Depth I I Eastern Surface Seal Installed by I <br /> Repair Work Done L3 Type of Pump H.P. State Work Done77- <br /> Well Destruction © Well Diameter Sealing Material 6 Depth - <br /> ihh Depth I Filler Material. & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I Wo septic system permitted if public sower is <br /> available within 200 lest.] <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> R0'0_ <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 . , J Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Lengthof lines Total length/size .. <br /> FILTER BED C7 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS GI 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_,,r <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: '9 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." I <br /> The applicant must call for all required''!ns ctions. Complete drawing on reverse side. _ <br /> Signed -I—C-" �C�lfc�r �- C Title: / . Date:.^� ' l 71 T l <br /> i R DEPARTMENT USE,ONLY <br /> Application Accepted by _� , *�"+� — Data �' ®Arre�a <br /> Pit or Grout Inspection by D to Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies.tot Ban-Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> S FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEI} -. CASH RECEIVED BY OATS PERMIT N0. <br /> ' �•�y�] �j t� ,u1 �'� Ftp <br /> . Eµ13-21 IAEv.f/N5; ,�hGP � t si� 3. �ZS�J C`� S te'f 0-Q`� <br /> EH 14-2e ✓✓ <br />