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APPLICATION FOR PER <br /> 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> L :1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> f P O BOX 2009, STOCKTON, CA 95201 <br /> REMIT RES 1-YEAR FROM DAZE ISSUED} r <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 Serfvices. �" <br /> Job Address 1®"`q-7 � City Q� Lot Size/Acreage <br /> { 'W� f <br /> Owner's Name iNLT `�-z'-3 COLI`Address Phone 5 1 I 34-29 <br />' Contrattor M �F�,� Address O +�aN 24/� 4 <br /> -- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR;C.- OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 1 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL II,'PITS/SUMPS _ <br />` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (") Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public la Other I n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Dona_ <br /> Well Destruction ❑ Well Diameter ..Sealing Material & Depth �_�_ <br /> 4 Depth t Filler liateridl &rDepth <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION-(Sr DESTRUCTION I I (No septic system permitted if public sewer is ) <br /> available within 200 feet.) <br /> Installation will serve: Residence` Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:) Y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg! Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> Method of Disposal <br /> ' <br /> J e Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ef No. & Length of lines - I L'u Total length/size— <br /> FILTER <br /> ength/sizeFILTER BED CI Distance io nearest. Well fJVt Foundatn ioProperty Line p'( <br /> 1 <br /> SEEPAGE PITS 11 Depth I Size r t Number `' <br /> ti SUMPS LI Distance to nearest: Well j .Foundation Property Line f� <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt bedone 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 signatur6 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 rformance of the work for which this permit is`issued, I shall employ persons subject to workman's compensa- f <br /> tion laws of California." "� <br /> The applicant mu call for all irsd in ctions. Complete-drawing on reverse side. f <br /> Signed X Title: Date <br /> t AftWf*T _4SE ONLY " <br /> Application Accepted by r. <br /> J4 1 Date Area <br /> r <br /> Pit or Grout Inspection by %` -bate Final Inspection by.r ! # Date �tF <br /> Additional Comments: 1 <br /> Applicant - Return a.11 copies to: I San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> C-1 X601 E. Hazelton Ave.-P O .Hox 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT£ PERMIT N0. <br /> INFO CASH <br /> * EH14*20IREV,tiN51 1 � Le�-9! A� f{`I� <br />