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I1111r 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 O BOX 2009, STOCKTON, CA 95201 <br /> RMW T EXPIRES 1 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ l �� /�J City Lot Size/Acreage <br /> Owner's Name �"f'*'L L L . ..._ t 3 23` .r/�.�IS_. �'r 'T�'-a�l� °S`�6 <br /> Address Phone936 <br /> f <br /> Contractor� Address License No. Phone <br />` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial, El Open Bottom 1:3 Manteca Dia. of-Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑-Gravel Pack L1 Tracy Type of Casing. �Il,�;.,., Specifications <br /> I'1 Public f_1 Other ❑ Delta Depth of Grout Seal _. ��O Type of Grout <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump t T H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter _i0 Sealing Material & Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 teet.l <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 _ ' C1 No, & Length of lines Total length/size y <br /> I <br /> FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS Ct Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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."Contractors hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ai call for It re ui inspections. Complete drawing on reverse side. <br /> Signed X jf Title: Date: <br /> ;�FORARTMENT USE ONLY I' <br /> Application Accepted by Date2-f <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 26 <br /> Additional Comments: yy <br /> Applicant - Return all copies to: San Joaquin County Public Health 1 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CACK RECEIVED BY GATE PERMIT'NO, <br /> E <br /> INfO �r� �y ��,�j <br /> . CH 19.24 IREV,riHSS 4,(,(4-0-,DT.?. t� ®S�� �/ G go "c-E'c'( <br /> CH A-269p <br />