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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 /> PERMIT EXPIRES 1 YEAR FROM DATE IS5UED <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address 431 City Lot Size/Acreage <br /> YZ <br /> � r • y� <br /> Owner's Name . 3 Address/' 4 01 Phone 7LOO `r <br /> � <br /> Contractor AddressLicense No_ _ / 6 13 23 Phone <br /> �-�-t" _ <br /> TYPE OF WELL/PUMP: NEW WELL 1) WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C1Monitoring Well C] <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 /> L) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WeII Casing <br /> ❑ Domestic/Private ❑ Gravel Pack LJ Tracy Type of Casing Specifications <br /> 1'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I i trriHation w,_Approx. Dept I # Eastern Surface Seal Installed by <br /> o � <br /> Repair Work Done H' Type of Pump H,P. ZSR State Work Dons _ --- <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth f Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 t REPAIRIADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is <br /> available within 2.00 feet.1 <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms Y <br /> Character of soil to a depth of 3 feet: f J Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg' J t Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: ,Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <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 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 /> The applicant must call for all required inspections. Complete drawing on <br /> reverse side. <br /> Signed X 16L_ �✓�tilia: /r ?� Date: T <br /> I, EPARTMENT USE ONLY p <br /> Application Accepted by G1tw VtA. ► Ace- Date ��a-� f-� Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Sass Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IN E AMOUNT DUE AMOUNT REMITTED CKSH RECEIVED BY DATE PERMIT'NO. <br /> . EH i3-2a1AEv.iiKsi Q <br /> EH it-Ze <br />