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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A / <br /> ENVIRONMENTAL HEALTH DIVISION INDGo _�/ <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 NN00y V3 A- <br /> PERMIT <br /> l/e�•yf <br /> EXPIRES 1 YEAR FRQM 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 compliances with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> [� + Cit Lot Size/Acreage <br /> Joh Address 7 7 iz �t-� y <br /> Owner's Name - ✓ r Address 4s `x ;I* - Phone <br /> Contractor Address Ve License No:;&M0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USI= "s TYPE OF WELL f PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ' El Open Bottom j El Manteca Dia. of W�Exca Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack 0 Tracy T Specifications <br /> ['I Public f 1 Other II De Depth of Grout Sea] Type of Grout <br /> I I Irrigation _4 Appro I Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter F Sealing Material 8 Depth, n <br /> Depth t Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I -REPAIR/ADDITION-[ I.41D�STRUCTIO (No septic system permitted if public sewer is <br /> T available within 200 feet.) <br /> Installation will serve: Residence F� Commercial— Other I W <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet. f e---! Water table depth <br /> SEPTIC TANK. ❑ Type/MfRl3 } Capacity - -� No. Compartments <br /> PKG. TREATMENT PLT.❑ hl W '' Method of Disposal <br /> Distance to nearest: i Well r Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines,' - - Tota] length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth i Size Number <br /> t SUMPS LI Distance to nearest: Well Foundation Property fine <br /> DISPOSAL PONDS ❑ I j <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 laws, and <br /> rules and regulations of the San Joaquin County..__.,.. _... _.s-_-- L _ --- z. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perfarmance 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i The applicant st call for all required inspectto s. Complete drawing on�rreeverse side. �-J <br /> Signed Title: [ /1 Date: / �^ <br />' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3-1(.` Area /1 <br /> Pit or Grout Inspection by Date Final Inspection by Date U <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 /> INFO AMOUNT DUE ( AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> � t <br /> i (REV' <br /> r/r$ <br /> 1 <br /> Ell 14-26 <br /> (- ✓ fJ CJ f . <br />