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APPLICATION FOR PERMIT <br /> SAN J•OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> 4 P O BOX 2009, STOCKTON, CA 95201 <br /> 4 R$I MIT 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 /> r application is made in compliance with San Joaquin County Ordinance No, 5h9 and 1862 and the Rules and Regulations of San <br /> f[ Joaquin County Public Health Services. <br /> Job Address f f A'1 City 4QT4/_POPLot Size/Acreage <br /> Owner's Name 6 ::5 L Address Phone <br /> Contractor Ae' r �CJf cc, _Address ¢ �1 n <br /> � _ License No.dc L�d Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION =x '4 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f 7 Industrial i Open Bottom D Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> fa Domestic/Private L] Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public f-I Other -f1 peiti Depth of Grout Seal Type of Grout <br /> I I Irrigation ApproK. Depth I I Eastern Surface'Seal Installed by <br /> Repair Work Done; U Type of Pump . a H.P, State Work Done <br /> Well Destruction0, Well Diameter r � Sealing Material & Depth Y <br /> Depth ! Filler Material 6 Depth y x � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I—DESTRUCTIONlON I-I' " <br /> (No se tic system P Y permitted it public sower is � <br /> ' -»__ r. available within 200 feet,) <br /> Installation will serve: ! Residence Commercial— Other <br /> Number of living units: <br /> �_.. Number of bedrooms—a <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK. ,❑ Type/Mfg f -j` Cay otic <br /> P Y No. Compartments <br /> PKG. TREATMENT PLT.�7 1 , �' - Method of Disposal <br /> Distance to nearest: *Well �r�,f Foundation `R F� <br /> ti 6�-=�F, �[ Property Line <br /> LEACHING LINE 0 No. & Length of linesTotal lengthlsize Q C---r <br /> FILTER BED ;' Distance <br /> 1o nearest: Well <br /> jl° Foundation � Property Line <br /> �` q <br /> SEEPAGE PITS f,l Depth i Sire _ Number l <br /> SUMPS L1 }Distance to7nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ,n ► <br /> I hereby certify that I have prepared this application and that the work wilt 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 certifievthe`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 applicant must call for I required inspe tions, Complete drawing on reverse side. ' <br /> Signed X I.L ' , / <br /> -Title- Date: <br /> .. �. .... e: .-..._ <br /> FOR PART T USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Date <br /> Additional,Comments: <br /> Applicant Return all'copies to: San Joaquin County Public Health <br /> r Services, Environmental Health Permit/Services <br /> 1641 E. Hazelton Ave:; P,b Box 200,9, ,Stockton, CA`95201 <br /> FEEL AMOUNT DUE' AMOUNT REMITTED CK ~RECEIVED BY DATE PgRMIT ND. 4 x <br /> INFO' _ — CASH �. _ <br /> a <br /> EH 1124 MEV.r/N51 <br /> EH 3-26 Q <br />