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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 JZZ / AOt <br /> - �- -MIX 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 <br /> �,Public Health Services. V1N�f�& S � <br /> V � <br /> .lab Address// 22_5-`-03 — 64'7 Lot Size/Acreage <br /> /7 Sig-2 <br /> Owner's Name may XPL "Arjd- — Address "' �5 Phone <br /> t <br /> Contract � ddress 225 r�r �f'1 ST License Nv.���r�[,7� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ e ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER1, 11j1 T�ZST B 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 9 1:1 M P 6- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G fr <br /> * Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing <br /> I'i Public 1:1 Other fl Delta Depth of Grout Seal Type of Gpsw6— <br /> I I l(rigation <br /> 11' <br /> Approx. Depth I ) Eastern Surface Seal Installed by 1� <br /> Repair Work Done D Type of Pump H.P. 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 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it 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 feet: Water table depth q <br /> SEPTIC TANK. 0 ,Type/Mfg Capacity No, Compartments f <br /> PKG, TREATMENT PLT. ❑ 1� Method of Disposal )"S <br /> iDistance to nearest: Well Foundation Property Line <br /> f ii <br /> f � <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED C7 J Distance to nearest: Well Foundation Property Line <br /> .y <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 San Joaquin County <br /> Home owner or licensed 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 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 st call for atl ed inspections. Complete drawing on reverse side. <br /> Signed X_______ i 1 Title: 6 Date: <br /> ?I! FO DE RTMENT USE ONLY <br /> Application Accepted by ! Date r d Area <br /> .i <br /> Pit or Grout Inspection by �� Date Final Inspection by Date d c/v <br /> Additional Comments: li <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> q Services, Environmental Health Permit/Services <br /> ii <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> F MOUNT DUE AMOUNT REMITTED GK RECEIVED BY DATE PERMIT'NO. <br /> IN CASH <br /> r EH 13-24 IREV-t/x 51 <br /> EH 14.26 <br /> r <br />