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n APPLICATION FOR PERMIT /V/ <br /> SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES <br /> ENW RONhdENTAL HEALTH DIVISION <br /> -A 1601 E. HAZELTON AVE�, 'PHONE (209)468—$420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> k9R dIT EXPIRES 1 UAR FROM• DATE ISSUED <br /> UED <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 b is ealth Servvices� 2/ —Z— <br /> Job Address City <br /> S� <br /> Lot Size/Acreage <br /> A70=0 1 <br /> Owner's Name .ohl) �`-'' "" Address 7X� ���� ���� -J�Phone ✓ �I v� <br /> Contractor Lr� i+ �✓+Addres,��e ` 27 if+0 -- L`icensJd�3'-�Phone d/0 2- <br /> TYPE OF WELL/PUMP: NEW WELL 0' WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> d, <br /> PUMP INSTALLATION, Cl L�� j SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK) SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF 1NELL� PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> s <br /> Feomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public I.l Other Cl Delta r- Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. De th I rn 1}� f,urface Seal Installed by <br /> Repair Work Done Ip Type!of Pump H.P.{I /i Ir/ _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAODITION i I DESTRUCTION I l lNo septic system permitted if public sewer is <br /> available within 200 feet.► <br /> iInstallation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG" TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D Nn:-&, Length of lines <br /> Total length/size q <br /> F FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE-PITS', l I. Depth Size Number <br /> SUMPS U Distance to nearest: Well. Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 SanlJoaquin County '__1 +� <br /> Home owner or licensed 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' such man ►es to become subject to workman's compensation'laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the foil mg: "I certify t et in the pert rmance work fo which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of lifornia." <br /> _.,,.,,The.applic t.-mu .-a f. <br /> squired C ete dr wing on~ stile: <br /> Si6nod <br /> Title: Date: <br /> c F lR SE ONLY <br /> Application Accepted by Date *`Area <br /> Pit or Grout Inspection by Date Final Inspection by - r Date 2-1 Rr <br /> Additional Comments: , <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> P <br /> t INFO ,AMOUNT DuE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> f pp <br /> 4 . EK13.2 Li[HEV. /K5S �EH 1,4111D � Q 1 ,7e <br /> A / <br /> a� _ <br />