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APPLICATION FOR PERMIT <br /> W SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES I YEAR FROM DATE ISSUED <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 10 <br /> Sh Services. ,t^ <br /> Job Address City Lot Size/Acreage 1! <br /> Owner's Name Address Phone <br /> Contractor Address pLicense No.,3AV 7_1 Phone 1;C5 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> — FOUNOAT40N AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 3 <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 /> Cl Domestic/Private - ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Public FI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation _.Approx. Depth € I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done , <br /> Welt Destruction ❑ Welt Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION i I Mo septic system permitted if public sewer is ! <br /> available within 200 feet.) <br /> Installation will serve: Residence 111 <br /> Commercial— Other <br /> Number of living units: _L Number ofb drooms <br /> Character of soil to a depth of 3 feet: ._ k _,..__._._. Water table depth / <br /> SEPTIC TANK C11-- Type/Mfg C_6b 0A.&dZ - -IbVC Capacity OL? <br /> & No. Compartments <br /> PKG. TREATMENT PLT, 0 ' Method of Disposal <br /> Distance to nearest: Well QG / Foundation /0 Property Line �Qa <br /> LEACHING LINE f <br /> L� ,No. & length of lines �� �_ � r Total length/size <br /> FILTER BED CI Distance to nearest: Well ia2 0 Foundation Q I Property Line �e& _ . fit <br /> SEEPAGE PITS A-(Depth a2 s t _Size t Number `T <br /> SUMPS LI Distance to nearest: Well 5 Foundation AVE4 Property Line Q _ <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, 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 subcontracting 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 applicant must call for all yfiquiod inspections. Complete drawing on reverse side. <br /> C n <br /> Signed X Title: <940AXp� Date: __ —/K— 7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b i <br /> Y Date C �1 7 _ Area U <br /> Pit or Grout Inspection by Date Final Inspection by - Date <br /> G ' <br /> Additional Comments: y j <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 <br /> INFO tAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH I4 •�IAEV,1/8 sr t �� 1 t d S 9- <br /> id-?N7 cd <br />