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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) 468--3420 <br /> P O BOX 2009, STOCETON, CA 95201 <br /> pgMIT RES 1 YE R FROM DUE ED <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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> J ui.n County Public Health Services. <br /> Job Address <br /> E. A S a s 7 o n City Lot Size/Acreage <br /> ��++ d Phone y6 277 <br /> Owner's Name J fFeay G ZP eE22V C'! Address <br /> tractor <br /> ` Address License No. Phone <br /> f ervice well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well (3PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca <br /> [7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'1 Pubtic 11 Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Hone <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION K <br /> iNoseptic system <br /> emitted it public sewer is <br /> availabInstallation will serve: Residence— Commercial_ Other t' J <br /> Number of living units: Number of bedrooms `1 f <br /> Character of soil to a depth of 3 feet: Water table depth t <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 C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 at 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 Iowa of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> igned X � _ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dat Area �7 <br /> Pit or Grout Inspection by Date Final Inspection b Date ]� <br /> Additional Comments: r 6 ,00 <br /> Applicant - Return all copies to: S Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> F££ A OU NT DUE AM UNT REMITTED H RECEIVED BY DATE PERMIT NO. <br /> INFO Y �} <br /> EM 13-241REV. <br /> EH U-2a <br />