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r APPLICATION FOR PERMIT <br /> i SAN .IOAQUINRONM COUNTY HEALTHEALTH HIV DIVISION <br /> SERVICES <br /> ENVIV614 1601 p-O AO%L2 09E,vSTOCKTON, CAo95201r3420 <br /> EAR FROM DA E � <br /> PEMLT EXPIRES 1 Y <br /> (Complete in Triplicate) <br /> in <br /> ppP lication is hereby made,to San Joaquin County for a permitditnanconstruct and/or and Instal theeRules en dwork eRegulationsdof Sans <br /> 4 <br /> f application is made in compliance with San Joaquin County <br /> r Joaquin County Public Health Services. T <br /> ..................... A id City Lot Siz /Acre JPO ----- <br /> Job Address - 2 <br /> s <br /> Phone <br /> Address <br /> ` Owner's Name e` _ <br /> License-No.538.0_- —phone <br /> Contractar_-1 y Pr�e�S - Addre.ss. 7 <br /> WELL REPLACEMENT C� DESTRUCTION D Out of Service Well j,L-11 <br /> i TYPE Of WELL/PUMP: NEW WELL OTHER D Monitoring Well -❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ <br /> ! DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' Dia. of Wel! Excavation Dia. of Well Casing <br /> C7 industrial Open Bottom ❑ Manteca Specifications <br /> ' [} <br /> Domestic/Private, D Gravel Pack L7 Tracy Type of Casing <br /> I'1 Public 1-1 Other <br /> n Delta Depth of Grout Seal Type of Grout <br /> I Irrigation —.Approx. Depth t I Eastern Surface Seal installed by <br /> H P State Work Done <br /> Repair Work Done CJ Type of Pump Sealing Material Depth <br /> Well Destruction C] Well Diameter Filler Material & Depth <br /> Depth ;~---....-_.�....- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t :�EPAIRlA'DDITION i I DESTRUCTION i I afvailabPerc system w Thin 200 feetit'ed if public sewer is <br /> InsBttafie a: Residence Commercial Other <br /> I I be.of bedrooms ` - <br /> Number of living units: �v <br /> i ,•-�l Water table d <br /> Character of soil to a depth of 3 feet: <br /> D Type/ ompartments <br /> SEPTIC TANK, <br /> Mfg Capacity <br /> ,t Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance?tondarest: Well 1 Fo roe roperty Line <br /> r y � <br /> D No. flr Length of lines Total length/size <br /> LEACHING LINE n, { <br /> FILTER-BED = --W-'- }- Distance to st Wall <br /> Foundation Property Line <br /> i <br /> I lire Number <br /> SEEPAGE PITS Depth s <br /> SUMPS Cl Distance to nearest: Wel! Foundation Property Line <br /> 61SPOS' L 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, a�d <br /> rules and regulations of the San Joaquin county <br /> me 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 /> ! am,-P10,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 issueensa- <br /> d, I shall employ persons subject to workman's comp <br /> tion lavas of)California." `•� <br /> r <br /> The applicant ust for all required in ct\s. Complete drawing on revers ide. <br /> Title: Date. <br /> Signed X _ <br /> FOR EPARTMENT USE ONLY <br /> ! .-...�....��'�-.` Date rea <br /> r Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or out Inspection by ,t <br /> Additional Comments: <br /> } Applicant - Return all copies to: San Joaquin County Public Health 4 <br /> Services, Environmental Health permit/Services T . <br /> 1601 E. Hazelton Ave., P 0 Box 2009,, Stockton, CA 95201 I <br /> �- -- <br /> . < <br /> ETTEOCK. _ _---RECEIVED-SY --DATE —PERMfl-N0-"AMOUNT-DUE— "AMdURNTECASH -, <br /> 1;0 <br /> � <br /> EH 3-24 IRtV. <br /> �(J1]• <br /> -� <br /> EH 14.28 �. �' <br />