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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, STOCKTON, CA 95201 <br /> EM11 EXPIRES 1_YEAR FROM DAIS' ISSUED i <br /> (Complete in'Triplieate) <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the work herein describX,1Tis <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Safi 4 <br /> Joaquin County Public Health Services. `� { <br /> Address /�f� -- L�VCX�t� IIC./ l t� City R1 Lot Size/Acreage- <br /> Job <br /> Owner's Name Z�4`� - 142elg./J9 4!5: /_ Address ^����! ��"Jv/P1�L> Phone ' <br /> Gantractor °�/.Li �"C. 12 Address E� License lVoa. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION Ll Out of, Service Well ❑ <br /> PUMP INSTALLATION C7 SYSTEM REPAIR © OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"l Public D Other F] Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth t� <br /> Depth Filler Material & Depth \\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted if public sewer is <br /> Z <br /> available within 200 feet.f <br /> Installation will serve: Residence L Commercial_ Other <br /> Number of living units: 4__ Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg P,4 4,L__ 12Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ `G" Method of DD�ispoossal <br /> Distance,.to l <br /> to nearest: Well Foundation-��=- Property Line�7--. <br /> LEACHING LINE Cl No. & Length of lines Total length/size f <br /> r <br /> FILTER BED C7 Distance to nearest: Wel! 11'�Foundation . Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS w _-....-,� a- l Distance to �eare'st:'r We(11 i` ' Foundation 7,/� Property Line <br /> DISPOSAL PONDS -- 17..q- <br /> 1, � <br /> D ❑ �� t <br /> dahereby-certify thai Chive prepared this application and that the work will be done in accordancd.with San:Joiquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agents`signature certifies the following: "I certify that in-the,performance_of the work for which this_pormit is,issued, I shall not <br /> employ any parson"in such manribr as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies thelolloyving: "I certify that in the performance 6f 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 must call for all: quired'4 spectipn Complete drawing on rev a side. t <br /> { ' e <br /> s <br /> _ . Signed K ' � Tide: ��[ 'Date: �t� <br /> ,` <br /> s FOR DEPARTMENT..lJ5F_ONLY <br /> Application Accepted by, ' ' '�' Date <br /> it or out Inspection by' Dater' incl Inspection by Date <br /> Gr <br /> �! <br /> Additional Comments: f <br /> {]f- Applicant - Return all. copies•to:,. San Joaquin County Public Health <br /> y 4, Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> r INE0 AMOUNT DUE AMOUNT REMtTTED I CASH RECEIVED BY DATE PERMIT NO. <br /> F <br /> a EH 13-24•IAEV.I/As) - �„�-� -- t O•� � Q <br /> EH 54:26 f'� - .1... t- <br />