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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 BOR 2009; :STOCKTON;"''CA 95201 <br /> ..,. i ' MIRES 1 -YEAR FROM=DATE: + ", <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin'County for a permit'to'construc'V&L/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No.,5k9 and 1862 end the Rules and Regulations of San <br /> Joaquin County Public Health Services. 71, ,.r t.;_�t 4--,- Its - h. I <br /> 5 �'City, F ; T l; . .. - r <br /> Job Address Lot"Size/Acreage <br /> C _ <br /> Owner's Name Address P IJ � 57-5- , Phone s� <br /> Contractor r'rK r- Address a��e /�OQ� Litense No. ps Phone_ -03 <br /> TYPE OF WELL/PUMP: w _ , NEW.WELL,EA1._ . WELL REPLACEMENT.[] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAf"FLD. PROP. LINE <br /> > FOUNDATION AGRICULTURE.W.ELL OTHER WELL. PITS/SUMPS <br /> INTENDED USE; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s/ <br /> C] Industrial '�'j ❑ Open Bottom Cl Manteca Dia- of Well Excavation �� Dia. of Well Casing <br /> Domestic/Private 1)1�Gravel Pack_ ❑ Tracy---W----�-Type-of-Casing - Specifications <br /> ' i'1 Public i.-1 Other _' ❑ Delta Depth of Grout Seat Type of Grout M <br /> I I lai ation T Approx. Depth I 1 Eastern Surface Seal Installed by <br /> ! Repair Work Done ❑ Type of Pump ►!1 �- H.P.- State,Work-Done _ <br /> Well Destruction ElWell Diameter Sealing Materiel & Depth <br /> Depth Filer material & Depth; <br /> TYPE OF SEPTIC WORK:- NEW INSTALLATION (,I -,REPAIR,/ADDITION 1-1-a-DESTRUCTION-{•I-ANo septic system permitted if public sewer-is <br /> available within,200 feet.) <br /> Installation will serve: Residence ''L Commercial­ <br /> Number of living units: Number_of bedrooms,I <br /> .;_. t <br /> Character of soil to a depth of 3 feet e Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg u Capacity" `_r No:Compartments <br /> PKG. TREATMENT PLT. ❑ _ _ _ Method of.Disposal <br /> Distance,to nearest:=Will - 44�Foundation Property Line <br /> r LEACHING LINE ❑ No. & Length of lines ``QIP Total length/size ' <br /> FILTER BED D Distancegto nearest: Well Foundation, Property Line <br /> SEEPAGE PITS 11 Depth :C Size e ' _ N'Number ' <br /> SUMPS Cl Distance:to nearest: Well (Foundation,_ • Property Line <br /> DISPOSAL PONDS ❑ + t ' <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: 1.certify_that in the.performance.of thew klor which this permit is issued,.I shall not <br /> employ any person in such manner as 6 become subject to workman's compensation laws.of California." Contrac'tb0s,6ine.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.empioy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicanvT11t1S1 call for all re ins Complete"raw' on reverse side. .. /` '7 <br /> f Signed- - ir),�•/ ___._.-. ^•Dater 0 <br /> Y _x F DEPARTMENT USE-ONLY - --* - <br /> .. {� s i Y -,.. <br /> i Application Accepted by Date - t �� Area <br /> Pit or Grout Inspection by Data Final In <br /> )) spection by <br /> Additional Comments: <br /> Applicant - Return all copies to, Sar► Joaquin County Public Health <br /> itServices. Environmental Health-Permit/Services r\ <br /> I 1601 E. Hazelton Ave.,.P 0 Box 2009. Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, <br /> INFO p (� <br /> . EH13-2/(REv.tfns) ��r$U �3�, t3-i� 30^ Il� l0� �- `�' <br /> EH 11.19 <br /> ' efa _a oo P <br />