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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct amfor install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 d 1862 the Rules and Regulations of San <br /> Joaquin County Public Health Services./ <br /> Is <br /> Job Address J� L �L�' ._ City Lot Size/Acreage 11 t <br /> � — <br /> Owner's Na ®` �✓ Address Phone <br /> Contfa,tC9X_&i <br /> Address License Nd-'��cu Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M_ DESTRUCTION ❑ 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n dustrisl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> /////I'1 Public L Other Delta Depth of Grout Seal Type of Grout__ <br /> I # Irrigation ___.. Approx. De � Eastern Jurface Seal Installed by <br /> p <br /> Repair Work Done 0 Type of Pum ..f H,P. State Work Done 1 1w <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <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 /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Companments <br /> PKG. TREATMENT PLT. ❑ 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 Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line _ <br /> DISPOSAL PONDS ❑ <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 o workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the follo ng: "I certify that in the parlor ce f the work for which this ermit is issued, 1 shall employ persons subject to workman's co ensa- <br /> tion laws of Ca'orhis.11 ?1 <br /> The applica u t call for all r uir d ins cti s, plat drawing on erg 'side. � <br /> Signed ' Title: Date: <br /> �j FOR DEPARTMENT USE ONLY �1 <br /> Application Accepted by - i X1w . �E Data ?�''��n1 � Area C <br /> Pit or Grout Inspection by Date Final Inspection by T� Pate <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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> + EH 131451 <br /> EH <br /> 1/ hs <br /> E H 714-211124 <br /> 4.2e 1 <br />