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- i <br /> 4 <br /> APPLICATION FOR PERMIT <br /> c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> t` P O BOR 2009, STOCKTON, CA 95201 . <br /> r f <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 /> I Job Address E City? <fo, Lot Size/Acreage <br /> Owner's Name Address ! `�� �� LiSr1Yf ��s .-- Phone �l <br /> Contractor A/e /'7iZ-I—le" Address License No-:2>5-d1-;:2- Phone <br />} TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Ca <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E <br /> C.I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> l <br /> d l Domestic/Private r ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public f-1 Other , n Delta Depth of Grout Seal Type of Grout i <br /> I { Irrigation _Approx. Depth I I Eastern Surface Seal Installed by. <br /> Repair Work done o ❑ Type:of Pump - H.P. State Work Done _ <br /> Well Destruction C) Well.Diameter- f' Sealing Material & Depth• <br /> " Filler Material & Depth <br /> ;Depth �,•, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AOOiTION I f DESTRUCTION i I iNo septic system permitted if public sewer is <br /> � <br /> ' available within 200 feet.) <br /> Installation will serve: Residence Z: '=C4ommercial Other y-• <br /> Number of living units: -I— Number of bedrooms a / <br /> .Character of soil to a depth of 3 feet: I 1 DO�� Water table depth <br /> SEPTIC TANK. Yom❑ Type/Mfg PAAk _ Capacity No. Compartments <br />{ PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ^Well l rS Foundation ` Property Line 62!-E <br /> LEACHING LINENo. & Length of lines, - `- --'C50 � —Total lengthlsizey <br /> FILTER BED Distance to nearest: Welles+� Foundation- / Property Line 5-0 <br /> SEEPAGE PITS I I �Deptfi ,y��, �� '^--Size 7� _ Number <br /> SUMPS Distance to nearest: Wellh= Foundation r �T' Property Line <br /> DISPOSAL PONDS O <br /> I 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 /> i <br /> rules and regulations of th,e San Joaquin County <br /> Home owner or licens_ed,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 signature <br /> certifies the following: "I cart ify 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 /> I i-The applicant must call for all re uirad inspections. Complete drawing on reverse side. i <br /> ;,Signed X Title: .. _ #-Date: -1�- <br /> FOR DEPARTMENT USE ONLY <br /> p Application Accepted by02.16 <br /> Date � U Area ` o <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> IApplicant - Return all copies to: San Joaquin County Public Hellth <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Boz 2009, Stockton, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK t RECEIVED BY DATE PERMt7'NO.- <br /> _ 3 GASHc <br /> INF0 � <br /> . EH 13-2401EV,tR5) <br /> 7i EH s4•2.6 ca <br />