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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)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RMIT EXPIRES 1 YEAR FROM DATE ED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sea 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 /> Job Address ���$ 1/NYZINY City Lot Size/Acreage <br /> go- k&wea- <br /> Owner's Name 11' r #I Address I�ey �j JVA1' 14 - Phone <br /> Contractor 0WORALe Address License No. Phone r �l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ ��/ ' i <br /> PUMP INSTALLATION E3SYSTEM REPAIR © OTHER O Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS acs <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z <br /> I-) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications J <br /> Il Public 1-1 Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done, <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONA REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-$- Commercial Other ? <br /> Number of living units: -Number of bedrooms 1� <br /> Character of soil to a dtsptfi/°f 3 feet: ��rr�, Water table depth <br /> SEPTIC TANK. [�' Type/Mfg Capacity.L1�,.^2� No. Compartments � <br /> PKG. TREATMENT PLT. ❑ ( Method of Disposal <br /> Distance to nearest: Well Foundation d Property Line <br /> LEACHING LINE No. & Length of lines `]a 7a 15 I To fal length/size <br /> r� <br /> FILTER.BED 0 Distance to nearest: Well� Foundation s Property Line 5 S <br /> SEEPAGE PITS l Depth -Sii Number <br /> i <br /> SUMPS LI Distance to nearest: Well 7_oa Foundation S Property Line <br /> DISPOSAL PONDS ❑ l\ <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 taws, 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(tiring or sub-contracting signature <br /> I 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 appli t must ca required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: f� <br /> IFORUEPARTMENT USE ONLY G <br /> Application Accepted by -� Date L Area <br /> or Grout Inspection by Date Final Inspection by' Date <br /> V <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services,. Eavironmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> S <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BYDATE _ PERMIT�NO. <br /> INFO CASH pp /�j !y I7 <br /> . EH 13-24 IREV.r/n 5) Q O� 7D UV2!�A S L__-� -A ` U �V °�1- <br /> EM i4-2E <br />