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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 O BOIL 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YEAR FROM DATE I aV—ED <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 /> 01-1 Got Size/Acreage <br /> Job Address $�3 G` • city <br /> Owner's Name <br /> SpPp; L 4 Address Phone <br /> ,�"�'^"Y _ <br /> 1.29r� _ c <br /> Contractor '` ��` Address b�` — License no.{,..,�__.-....�—Phone <br /> f Service Well Ll <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 1-7DESTRUCTIONC1 Out Monit ring well ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial ❑ Open Bottom O Manteca Pia. of Well Excavation <br /> Dia. of Well Casing <br /> Specifications— <br /> k1 <br /> k1 Domestic/Private CGravel Pack 0 Tracy Type of Casing — --, <br /> Type of Grout <br /> I•! Public FI Other n Delta Depth of Grout Sea! <br /> I i Irrigation __.Approx. Depth I ! Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump Srj�rn� 3a.SFf3(L H.P. K N` �t — State Work Done _ <br /> Well Destruction C1 Well Diameter <br /> Sealing Material & Depth <br /> Depth 1 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION { I DESTRUCTION I I (No septic system <br /> m permitted it public sewer is <br /> availabeet.1 <br /> Commercial_ Other <br /> Installation will serve: Residence` <br /> (� <br /> I 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 No. Compartments. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE Cl No. & Cength of lines Total length/size <br /> k FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS II Depth f Size Number <br /> SUMPS E Distance to nearest: Well Foundation Property Line <br /> t. N. DISPOSAL PONDS Cl 1 I <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 /> ify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <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 f towing: "I certify that iri the pertofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> i tion laws of .kornla," ' '. <br /> Tha applic t must call-for i! required in c f ons. C mplete drawing o verse side. <br /> Signed4 <br /> '! I r Title: � Date: <br /> 2 1ST <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health n <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK X <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 N0, <br /> INFO <br /> r �.ao �2- SSI C3I <br /> i + EN r3-241REV.1/ASI <br /> Hi 74.20 <br />