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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,C� �Q <br /> .I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 11MAIT 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 trade in ccnplianceiirith 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 y 3 C �Ia, ` City �-Iot Size/Acreage <br /> Owner's NameAddress : c�„ -- Phone <br /> Contractor ti!Z�_& PU411., +t4c ;q C�ak f ?p / <br /> Address ` License Nd. Z J 7--3 Phorte/_� 9+a�- <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ � T, SYSTEM REPAIR 0 OTHER p Monitoring Well <br /> EWER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SLINES DISPOSAL Fi_D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Nibftc 1.1 Other 17 Delta Depth of Grout Seal Type of Grout } <br /> + I Irrigation / — Approx. De th 1 I Eastern dace Seal Installed by `] <br /> Repair Work Done fa Type of Pump� �� <br /> t� " H_P, t State Work Done <br /> Well Destruction CIWell Diameter Sealing Material & Depth <br /> Depth ' r 1Filler Materiel b Depth <br /> TYPE-OF 5EPTLC,WORD(:—NEW.INSTALLATION,a�I=;AEPAIR/ADDITJON-1�1—DEST•RUCTION,d_I,.>(No-septic system-permitted if public sewer is <br /> available within 200 feet.) p / <br /> installation s <br /> allation will serve: Residence_ 'Commercial Other <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a depth of 3 feet: �'� i Water table depth <br /> SEPTIC TANK O Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ a I 1 <br /> I i Method of Disposal <br /> Distance to nearest: Well Foundation; Property Line , J <br /> LEACHING LINE ❑=�No;_&_Le_ngth,'of lines �• I Total length/size <br /> FILTER BED [] Oi is ante to nearest: Well Foundation' Property Line <br /> SEEPAGE PITS It Depth Size_ 1 i + Number ' <br /> SUMPS Ll Distance to nearest:)' „Weil Foundation Property line <br /> DISPOSAL PONDS py If <br /> I hereby certify that I have prepared thisapplic;tignd that the work-willib`e done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County i <br /> Home owner or licensed agent's signature certifies the foilawin9: "1 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 compensalion;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- <br /> tion laws of California." Ii <br /> The applicant t ca for ell requir insPections, Complete drawing on reverse side. <br /> Signed �^ �t <br /> Date: <br /> ENT USE ONLY <br /> Application AcceptedbyLA� I <br /> Date_ Area <br /> Pit or Grout Inspection by Date `�– Final Inspection by Date <br /> Additional Comments: <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 AMOUNT DUE ' AMOUNT REMITTED <br /> INFO K H RECEIVED BY DATE PERMI7'NO, <br /> r Elf 13-24 IREY,1/F51 <br /> EH14.20 <br /> t <br />