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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLICAHEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, 'STOCKTON, CA 95201 <br /> gF"TT 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 j <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 /> dN <br /> k_ City Lot Size/Acreage <br /> Job Address <br /> Address Phone <br /> Owner's Name <br /> / v <br /> hone <br /> Contractor Address G- "� -- License Na��✓ P— +" rr� <br /> f ervice Well LI <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION © out Moonitoring Well L]PUMP INSTALLATION ❑, SYSTEM REPAIR 0 OTHER fl <br /> DISTANCE TO NEAREST: SEPTIC TANK,_ ti--_SEWER,LINES, DISPOSAL FLD. PROP. LINE } <br /> FOUNDATION a AGRICULTURE WELL' OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA-_ CONSTRUCTION SPECIFICATIONS <br /> L] Industrial ❑ Open Bottom © Manteca'""' "Dia. of-Well Excavation Dia. of Well Casing <br /> ' ' R <br /> • Cl Domestic/Private Ll Gravel Pack ❑ Trac, �• Type of Casing Specifications <br /> I'1 Public _ <br /> C] Other n Delia` w Depth 76f.Grout Seale' Type of Grout <br /> I I irrigation —.Approx. Depth I I Eastern -r � Surface.Saul,installed by� <br /> H.P. # *'f State Wdrk Done SFr <br /> Repair Work Done U Type of Pump , 4 <br /> Sealing 1NateFial&-Depth i <br /> Well Destruction ❑ Well Diameter <br /> _, k. Depth I ., -1 Filler Material & Depth <br /> TYPE <br /> OF-SEPTIC'WORK: NEW INSTALLATION I L ;REPAIR/ADDITION DESTRUCTION # I INo septic system permitted if public sewer is <br /> _ _ available within 200 feet.) <br /> Installation will serve: Residence commercial_ Other <br /> - Number of living units: _ ,Number of bedrooms <br /> Character of soil to a depth of 3 Leet: Wates table;depth, <br /> SEPTIC TANK. ❑ Type/Mfg Caps rty No. Compa'rtrtlenfs'"' <br /> iMethod of Disposal <br /> t PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property'Line <br /> LEACHING LINE No. & Length of lines Totalrlength/size <br /> FILTER BED Distance to nearest' * `.Well foundation Property Line <br /> a <br /> IL <br /> �a SEEPAGE PITS 11 Depth `-T Siie. -ell �D - Nu r <br /> SUMPS . _ Distance to nearest: Well lca2 t� r Foundation lfr,7 Property Line <br /> k DISPOSAL PONDS Cl <br /> I hereby cartity 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 rules and regulations of the San Joaquin County , <br /> Home owner or licensed agent's signature certifielthe following: "I.certify that in the performance of the work for which this permit is issued, !shall net <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.ceriify that in the p 44&r nance of Ike work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of,California." <br /> The applicant 2:��for requi ed inspections. Complete.drawing!on reverse side. 9 - <br /> Signed X h _ Title! y�' Date: <br /> FbR"DEPARtMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date J Final inspection by <br /> Date_LT/_�b <br /> Additional Comments: ; <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> S6rvices. Environmental Health Permit/Services <br /> ' 1601 E. Hazelton Ave.,`P 0 Bax-2009, Stockton,..CA 95201 <br /> FEE .. «.AMOUNT DUES;: '*'AMOUNT'REMITTEO `CASH �, ""RECEIVED By— OA7E `_ PE3�Nll7_NO. <br /> INFO <br /> . EH 13.24 IAEV.II-sl Y �j�—S!9 q 7�Z.�,p� <br /> EH:4-29 _ <br />