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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 O BOX 2009, STOCKTON, CA 95201 <br /> RERMIT 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Heal h Sery ces. <br /> yo 3 /4/0-T Ew e�1,r,4�& <br /> Job Addresstti 1'y�r-2�l �!a�r�0 tll�y___ _-____ City �G_ Lot Size/Acreage � <br /> Owner's Name �— Address Phone W <br /> Contractor ll. f� �0/AF , Addr s l License No. Ph6n <br /> E OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYST REPAIR El OTHER ❑ Monitoring Well [3 {dam <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICULTU WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM E CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> C Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications <br /> fl Public CI Other Fl Del epth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth 1 1 stern ace Seal Installed by 4— <br /> Repair Work Done 0 Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Mater & Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTA"TION I 1 REPAIRIADDITION I I DESTRUCTIONiNo septic system permitted if public sewer is <br /> available within 200 feet,I <br /> Installation will serve: Residence_ Commercial Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table d$pth g- <br /> SEPTIC: TANK ❑ Type/MfgCapacity No. Compartments ` 1 <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line N <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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, <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 signatur <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 compens <br /> tion Eau's of aiifarnia." <br /> The applic nt call for all regal' d ins ions. Complete drawing on reverse side. p <br /> Signed Title: --_ v Date: 6�2 0 <br /> EPARTMENT USE ONLY <br /> Applicatigepd Date Area <br /> Pit or CirDate Final Inspection by Date <br /> Additiona <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 AMOUNT DU MOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, <br /> + EH17-24IREV � <br /> r7 �� ✓ ����p �'U-a2�S <br /> EH 74-M ` r©� 7 ���"` <br />