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A <br /> . - � 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 /> PERMIT 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. <br /> Job Address <br /> cq7:nW Al IY/Gh 1119'-'.-RJ _ City - Lot Size/Acreage <br /> - " <br /> 1 � r d <br /> Owner's Name. WL a h Address r S '`Phone c F <br /> Contractor f ` -t r+ Il Address a�0 80�L License Ho.g2 -tgUSPhone <br /> TYPE OF WELL/PUMP:: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ r <br /> -PUMP INSTALLA`TI,O,N� `----SYSTEM"REPAIR-C) ....------- "OTHER ❑ - ,Monitorinng-Well,,Xl <br /> DISTANCE TO NEAREST: SEPTIC TANK _i�,L� SEWER LINES DISPOSAL FLD._ PROP. LINE &L r, i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1SGsl <br /> INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y # <br /> E Industrial .X-Open Bottom ❑ Manteca Dia. of Well Exc Vation Dia. of Well Casing <br /> omestic/Private 0 Gravel Pack {CJ Tracy- Type of Casin Specifications <br /> I'} Public [:1 ner 11 Delia Depth of'Grout Seal GEou <br /> I I If6gation CP%C Approx. De�p+th �,I I Eastern rfa a Seal Installed by e. n�■ <br /> Repair Work Done ❑ Type of Pumpd2� _ H.P. State Work Done ��•] <br /> Well Destruction ❑ Well Diameter Sealing Mater al & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> 1 available within 200 feet.I <br /> Installation will serve: Residence_ Commercial•-r.. Other <br /> i Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth` <br /> SEPTIC TANK 0 Type/Mfg 'a Capacity"' - No. Compartments <br /> PKG. TREATMENT PLT. Cl a _.�_,�.,� "-•-�- -.. -- �, _ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ._...-❑ No. & Length of lines Total length/size <br /> FILTER BED 0 -Distance to neare_st:__ Walt Foundation -.-Property-Line. <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ,.CI Distance to nearest: Well Foundation Property Line <br />` DISPOSAL PONDS 1 Cl <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 wofk for which this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workman's compensetion 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- t\ <br /> tion laws-of.California." <br /> The applicant mut call for all required in ctions. Complete drawing on reverse side. <br />'r Signed Title: G Date: <br /> W 1 FOR DEPARTMENT USE ONLY <br /> Appliceti Accepted by Date Area j L <br /> Pit"or ro Inspection by Date 7 `T-!!%' !'-"Final Inspection by Date D <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Fnvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009.=.Stockton, CA 95201 <br /> k ' "FEE AMOUNT DUE AMOUNT REMITTED CK*CASH" RECEIVED BY DATE PERMIT•NO. <br /> a INFO �j � `I- fir{�j y'"i� <br /> ' . EH 13.24(REV. n Sl '/� `1`i'- 'l 4 I.i q0—tj 1L <br /> FH445 t[/- L <br />