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II <br /> 11 APPLICATION FOR PERMIT G 3 v <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ii 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> Ii P 0 BOX 2009, STOCKTON, CA 95201 <br /> II. <br /> 2ERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> f 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 /> L` !? 14 <br /> L <br /> Job Address Z T ,6 ' W G City `D /' Lot Size/Acreage <br /> Owner's Name _ _. Address � C -3Phon� L <br /> Contractor Address1> <br /> —License No.�?3�S Phone <br /> TYPE OF WELL/PUMP: i' NEW WEL�Lt� WELL REPLACEMENT El DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION"L-! SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - 2j2 SEWER LINES DISPOSAL FLD1_S0 PROP. LINE .�_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQW <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 Dia. of Well Casing <br /> �1 )LeDomestic/Private 1W Gravel Pack ❑ Tracy Type of Casinglei <br /> ,< Specifications <br /> €"1 Public D Other n Delta Depth of Grout Seal _ r—T Type of'Grout <br /> I ) Irrivation `�. —'Approx. Depth ILII Eastern Surface Seal installed by <br /> Repair Work Done U Type,of Pump H.P. ___ _� State Work Done _ /_ <br /> Well Destruction ❑ WeII'Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION_I 1 DESTRUCTION € I tNo septic system permitted it p}iblic sewer is <br /> available within 200 feet., <br /> Installation wr e: Residence--, Commercial— Other P 1 <br /> y� Number of living units: I€ Number of bedrooms <br /> Character of soil to a depth of 3 ~ Watatable depth 'nom <br /> SEPTIC TANK ❑ Tyge/Mfg Capacity No: Compartments ? 4 <br /> PKG. TREATMENT PLT. ❑ �� Method of Disposal 4 <br /> Distance to nearest: Well dation Property Line i <br /> �h LEACHING LINE, ❑ No. & Length of lines n9th/sire <br /> FILTER BED i 0 Distance to nearest: Well Foundation Prop ine � <br /> SEEPAGE PITSF 11 Depth Sire ,/ ' <br /> Number ' <br /> SUMPS Lt Distance to nearest: Well Foundation property Lina <br /> R DISPOSAL PONDS ❑ 11 '. 1 <br /> I hereby certify that I have prepared this application andthat-the work vv€Il'ba 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:€n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cartifies thefollowing: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensre <br /> tion laws of California." I <br /> t I' <br /> The applicant must'c 1 for all required inspections. Complete drawing on reverse side. �+ <br /> Signed X Tide: _4:21 -- _ Date: 67,/oP— I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dated Area �r M <br /> IIS G w <br /> Pit or Grou Inspection b i Date ��r 4 Final Inspection b Date^S d <br /> Additional Comments. GC, 110 3 ld7 & 76,1,Yi�- ¢ <br /> a <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> .11 Services, Eavironmental Health Permit/Services <br /> I� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CKS <br /> INFO MOUNT DUE AMOUNT REEMITTED CASH RECEIVED BY / DA/TE PERMIT'NO. <br /> . EH17.26 IREV.I i n sl <br /> EH 11.26 /14 ;;` /Os C3 ( 7e <br /> - _ <br />