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APPLICATION FOR PERMIT " ?6� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `T �j <br /> ENVIRONMENTAL HEALTH DIVISION O f7 -&60-3Z <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT UP <br /> IRES 1 YEAR FRAM_DATE IP$ 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 iB made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules a.ud Regulations of San <br /> Joaquin County Public �H1ealth Services.. <br /> .fob Address ,gFabl )J, r !/ { -City Lot Size/Acreage <br /> Owner's Name 1x-71 ¢ Address /' 6= a 3 �,��� it Phone3-3 F_771J_ <br /> , _ q � <br /> O Address T'���`�`� /d"�� License No �3 7 3 Phan C( � <br /> Contractor , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well L� <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL .—.OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> IX Public Ia Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I.Ir6 ation —.Approx. DepttV hI Eastern Surface Seal Installed by <br /> Repair Work Done ff Type of Pumper H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 f DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.I \1 <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: 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 /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED [1 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS if Depth Size Number <br /> SUMPS t l Distance to nearest: Well Foundation Property Line <br /> ._ DISPOSAL`PONDS- -❑ ­_ _ �- -u� ,P }T:_- --� —— ,...—ter ] <br /> I hereby cartity 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: "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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appiic n us t all for all re uired inspections. Complete// drawing on�re-verse side. Q/ <br /> Signed Xlie: y - Date: .-3 ` ! <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by '! Date ? �� Area ..�T <br /> Pit or Grout Inspeclion,.by Date Final Inspection by Oatea� <br /> Additional Comments: J <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMtTTED CASH RECEIVED BY DATE PERMIT'NO. 1 <br /> + EH 43.`24 IREV.f i nsl /� <br /> *EH 71.24 tet/ <br />