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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERUIT EXPIRES 1YEAR FROM DATE_ ISSUED � <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 compliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> k c G <br /> Job Address 1 City G v Lot Size/Acreage <br /> �I <br /> Owner's Name T . S ! Address Phone <br /> Po 91 K <br /> Contractor4,2-, ,� Address /4 License No. Phone y� <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER El Monitoring Well ❑ <br /> DISTANCE TO NEA.BEST:."SEPTIC TANK" SEWER LINES _ _ DISPOSAL FL_O. PROP. LINE <br /> # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> L7 Industrial ! ❑ Open Bottom ❑ Manteca ``V Dia. of Well Excavation Dia. of Well Casing <br /> 1-7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I <br /> I'I Public (-1 Other n 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 i ❑ Type,of Pumpr '-� ti.P. - ! State Work Done <br /> Well Destruction O Well„Diameter 4 Sealing Material & Depth <br /> DepW r _3 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I IN. septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Vr Commercial_____ Other` ` { <br /> Number of living!units: -(— Number of bedrooms i <br /> Character of soil;to a depth of 3 feet: ; t Water table depth r <br /> SEPTIC TANK. '0-y Type/Mfg _ : Li Capacity No.,Compartments <br /> PKG. TREATMENT PLT. ❑ .'; %, --, T j f:a Method of.'Disposal Z <br /> Distance to nearest Well, `5 0 "_ „Fbundation,/19C Property Line <br /> LEACHING LINE ❑ No. & Length of lines - ag)_ T-Ofal length/size O �� <br /> FILTER BED ❑ Distance to nearest: Well, D F ndat{on! 2 ' Property Line <br /> SEEPAGE PITS f I . Depth dd Size 4 �AW 2,/ 4' 2 r 'Nu nnber` r� <br /> SUMPS �, 1,Q~` Distance to nearest: Well b CFoundation./O Property Line <br /> DISPOSAL PONDS <br /> l <br /> I hereby certify that I have prepared this".,application and that the work will be done in accordance with San JoaquM county ordinances, state laws, and <br /> rules and regulations of the San JoaquinrCounty <br /> Home owner or licensed agent's signature-certifies the following; "I certify that in the performance of the wo'rli 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.” Coy trattof's hiring or subcontracting signature <br /> certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall amptoy persons subject to workman's compensa- <br /> tion taws of California." k r ", <br /> The applicant must call for all required inspections.-Compleie drawing on reverse side. "f <br /> Signed 7�_ - s•6��ti� Title: ——_ 1Date: �`5 ✓ <br /> ti <br /> ' ,FOR DEPARTMENT USE ONLY <br /> �21 <br /> Application Accepted by Date Area fp <br /> Pit or Grout Inspection by v j Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return.-a.lr copies-to:-San Joaquin--Colunty-Public-Health <br /> r Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P O'Box 2009, Stockton, CA 95201 <br /> FEE' �AMOUN"T DtJE�-: —AMOUNT-R&ITTED CK-"` RECEIVED BY­�-- DATE " ^PERMtT'NO."' <br /> _a INFOPCASH <br /> . EH14.2 IREV,r/HS! <br />- EH 11.20 <br />