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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 /> EMIT EXPIRES 1 -YEAR FR M DA ED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sari 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 /> Job Address 62i 1 AE AiQr?N LA U& City. � Lot Size/Acreage <br /> 1^Owner's Name'���.F— ER Y � _ f�js^ <br /> 1 Address Phone9 <br /> 1 S�1V <br /> Contractor <br /> Address License No � w Phone 6d <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE 70 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 /> r7'Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> Ca <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing s �' .�} Specifications t <br /> Public f.1 Other ❑ Delta Depth of Grout Sea! <br /> I I Type of Grout <br /> Irrigation -..Approx. Depth I I Eastern Surface Seal Installed,byf <br /> j Repair Work Done 0 Type of Pr k <br /> { ump _ H.P. � State Work Dona <br /> ' Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> _ � A Depth .».�tT -.- - -Filler Dfstesial & Depth <br /> 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ' DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200feet.► ; <br /> Installation will serve: Residence tCommercial Other <br /> Number of living units: t4 <br /> �_ �Number,of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> t Water table.depth r <br />{:,r' '"'SEPTIC TANK. )9, Type/Mfg '1 F—=! :0 L- Ca ;.» <br /> fi. C) �t t pacity�_ No.'tompart'ment9 <br /> PKG. TREATMENT PLT. <br /> { ..T,Method of Disposal <br /> Distance to nearest: Well 'F <br /> `Foundation ,fi `' , <br /> r Property.Line ` <br /> LEACHING LINE x(1571 1 No.t& Length of lines i Total length/sire t <br /> � FILTER BED C7 Distance to nearest: Wel! . ' <br /> r } , A Foundation Property Line. <br /> SEEPAGE PITS P Deplth Size Number f <br /> SUMPS LI Distance to nearest: Well Foundation <br /> D ❑ i ------- Property Lina <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, - <br /> I rules and regulations of the San Joaquin County state laws, and <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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature r <br /> certifies the following: "I certify.that'in-the-performance of the-work for which this permit is-issued, I shall e <br /> tion laws of California." '41 mploy persons-subject to workman's compensa- <br /> ry <br /> The applicant must call for all required i tions�Compfdrawing on reverse side. <br /> ; � s F <br /> Signe <br /> .aA Tine: Dew ✓' '`/f� �T <br /> FOR• iEPARTMENT USE ONLY-- .- II '/ <br /> ~ 'l0 (�' <br /> Application Accepted by Date Area <br /> s <br /> Pit or Grout Inspection by //11 Date Final Inspection by Date 69 ` `v2, <br /> Additional Comments: C 6,Cve If,�,t��yJ7r <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> .. t <br /> t '—Services,—khvitonmeatal'"Hea,lth'Pei�,i-t%Servicee�"'""- �dfo�t tAta-fir..��'f� dips 7 <br /> 1601 E. Hazelton Ave., P O 2009, Stockton, CA 95201 5 g.FEE <br /> r9` <br /> INFO AMOUNT DUE � AMOUNT REMITTED C K RECEEVED BY <br /> PATE, I PERM17'NO.' <br /> � EH 13-24 tREV.vttsl otr <br /> - <br /> EH 74-2e <br /> f <br /> ` 4. <br />