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ys APPLICATION FOR PERMIT a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T ry <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-342 k <br /> f"' <br /> I . <br /> P O BOX 2009, STOCETON, CA 95201 SEP 0 6 .- . � i <br /> pFMIT E%PIRFS 1 YEAR FROM DATE LaaVEBWRONMENTAL HEALTH � <br /> (Complete In-,Triplicate) PERMIT/SERVICES <br /> Application is hereby made,to SantJoaquin 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 /> City [e y--- — Lot Size/Acreage I <br /> Job Address <br /> Owner's Name ILJ + rasa <br /> ContractoowmEw_ Address nse Noc --Phon <br /> TYPE OF WELL/PUMP- NEW WELL WELL REPLACEMENT 0 DES7R0CTION C1 Out of Service well Ll <br /> i <br /> PUMP INSTALLATION D <br /> .f SYSTEM REPAIR ❑ OTHER IID 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 /> R Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing <br /> t <br />' fa Domestic/Private 'o–Gravel Pack C7 Tracy Type of Casing Specifications <br /> i.1 Other } I l Deelltta�,r� i Depth of Grout Seal Type of Grout <br /> 1 1 IniHat n T Pprox, Depth " }-4 Surface Seal Installed by <br /> Work Done I <br /> Repair Work Done L3 Type of Pump H.P. State <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth I <br /> :1 Filler Material & Depth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I 14EPAIR/ADDITION { I DESTRUCTION I I INo septic system permitted if public sewer is <br /> F available within 200 feet.I �v <br /> Installation will serve: Residence 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 i No. Compartments <br /> PKG. TREATMENT PLT. Clt; Method of Disposal <br /> Distance.to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> l - ,, <br /> t FILTER HED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS l Distance to nearest: Well Foundation_ Property Linei <br /> f DISPOSAL PONDS ��❑ <br /> I hereby certify that I have prepared this application and that the work will be dans 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 no. .. <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 cert 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 Ca' rnia." ' <br /> The appfic st fo all req r inspections. Complete drawing on r se side. <br /> Signed X Title: Date: <br /> a <br /> JR DEPARTMENT USE O YApplication Accepted by Date Area <br /> Pit or out epection by Final Inspection by Date <br /> (� J <br /> Additional Comments: <br /> Applicant – Returna]1 pies to: San Joaquin ount Public Health <br /> } Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEECK <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EM13-24IREV.r/ns" 9 `�� �O <br /> EM 94.26 1 <br /> f <br />