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APPLICATION FOR PERM I T <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 /> _2ERMIT EXPIRES I YEAR 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 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 -- t-0_ux-1-L __ City 5-k"t')t') Lot Size/Acreage <br /> Owner's Name ` � 1-J!J Address Sy�L�-L^ Phone f 'z'2 <br /> r r ��11 Q q(��^Q ,I <br /> Contra Oress �2-570 License No v 11 Phone -/ 7 J u <br /> TYPE OF WELL/PUMP: YNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLpry PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL; '"°PttTS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE CIFICATIONS � ' <br /> F1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation iia. of Well Casing <br /> Cl Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing specifications <br /> 1'I Public 1.1 Other 171 Delta Depth of Grout Seal ` 4ype odGrout II <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> .,,.,.. <br /> Repair Work Done L]- Type of Pum Sealing State,Work Done _ <br /> Pump � 1 <br /> Welt Destruction -`-❑ Well Diameter ng Idaterial & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADIDITIONA DESTRUCTION l Ik:(No septic system permitted if public sewer is <br /> available within 200 Met) <br />--&- —Installation—Installation will serve: Resf -idence : Cornmercia!� Otl'iei <br /> Number of living units: _._L___ Number of be roo s_ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg tf Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ i Method of Disposal <br /> Distance to nearest: Well U Foundatiori Property Line <br /> LEACHING LINE D No. & Length of lines 561 TO/at len th/size ` <br /> FILTER 8£D ❑ Distance to nearest: Well Foundatio roperty Li�„� � <br /> SEEPAGE PITS 1 1 Depth f7 r Size Numbel <br /> SUMPS Distance to nearest: Wel! Foundation F roperty Line <br /> DISPOSAL PONDS ❑ <br /> 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 ownei 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 j <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The app4icanust all to nspeetions. Complete drawing on r verse side. 4� Q <br /> Signed Title: Date: r t7 190 <br /> _ <br /> DEPARTMENT USE ONLY 7l/�(��/ <br /> Application Accepted by �' Da[e`WL�--�--fi--1� <br /> Ar a <br /> Pit or Grout Inspection by Date Final Inspection by Date `7 r�z 5 �Q <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 /> �: .rtiz: FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT�NO. <br /> {� INFO 'n• CASH �r Q <br /> .„.;EH13-24tREV.+ <br /> IRS 1 ��� G( '^'0 'Q JLQ� <br /> 1446 L �L <br /> t to -: <br />