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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / <br /> ENVIRONMENTAL HEALTH DIVISION f/ <br /> 1601 <br /> �,.. E. HAZELTON AVE. PHONE <br /> (209)4683420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT -EXPIRES I YEAR FROM ,DATE IQSUED <br /> (Complete in Triplicate) <br /> Application,( herebyiokde to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in�comp'liance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Puubblic Health Services. �J <br /> Job Address / a City oA 1 _.-Lot`Si'ze/Acreage 8$ 6 G' <br /> Owner's Name . L�., FiX' 1-:7,E I REQ I Address Phone 3 <br /> Contractor 00 J'Ael 1j14Address � Ok1- 'CA611_Licenseft.,�Rje L Phone 145--14#71 <br /> TYPE OF WELL/PUMP: NEW WELL , WELL REPLACEMENT ❑ <br /> DESTRUCTION D67 of Service Well LI <br /> PUMP INSTALLATION r. SYSTEM,REPAIR ❑ OTHER El Monitoring Well C7 <br /> 'DISTANCE TO NEAREST: SEPTIC TANK X.)Qi„-'SEWER LINES fj r i DISPOSAL FLD.L`(J1 PROP, LINE,B- j <br /> t�a d � <br /> FOUNDATION D AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r��1 <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 2` VT <br /> Dia. of Well Casing I <br /> Domestic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing it Specifications <br /> 1"I Public 1-1 Other C1 Delta Depth of Grout Seal Type of Grout <br /> I I Irritation �.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done' f7 Type of Pump —fu ub H.P. State Work Done <br /> _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth "4 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sews► is 4 <br /> ' <br /> Installation will serve: Residence— Commercial----: Other available within 200 feet.) <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. Compartments <br /> PKG. TREATMENT'PLT. ❑ Method of Disposal Q <br /> Distance to t nearest: Well Foundation Property Line ., <br /> LEACHING LINE Cl No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance tc nearest: -. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth j Size Number t <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ❑ { <br /> I hereby,certify that I have prepared this applicatiori 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 a <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, 1 shall employ persons subject to workman's <br /> compensa-tion laws of California." i <br /> 3 <br /> The applicant must call for all require inspections. Complete drawing on revs ode.el <br /> g <br /> e <br /> k Signed X Title: G �, <br /> ..� Date - <br /> OR11REPARTMENT USE ONLY y <br /> Application Accepted by Data! <br /> �}. Area <br /> Pit or�ort Inspection by 4� ate � ��1 Final Inipection by1 Data <br /> Additional Comments: 111 <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 CK RECEIVED BY DATE PJ RMIT'N0. <br /> INFO CASH <br /> . 4.1 <br /> EH 13.24 IREV.r t n 61 C <br /> EH 14.26 - \'a o —7-1 g^ <br />