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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 /> PERMIT EXPIRES 1 YEAR FROM DA,JE 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 Public Health <br /> Health Services. <br /> Job Address aF"� �. �1_bnn .(.,;('�;}�}'f..,_ Citygo Lot Size/Acreage <br /> Owner's Name 010LG.fJ I!�QC� A!G _ Address 'GQJM.1- Phone <br /> / t <br /> Contractor Address_LA� yrZfI� License No. 46 Phone <br /> �;. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ['I Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications <br /> I') Public El Other n Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrioation Approx. Depth I 1 Eastern S rface Seal Installed by <br /> Repair Work Done 0 Type of Pump -6f)V) _ H.P. State Work Done I <br /> Well Destruction D Well Diameter sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; ,.NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION l I lNo sepric system permitted if 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: �" VJPtfl/►'%M1r w�P} r <br /> SEPTIC TANK ❑ Type/Mfg Capacity— <br /> PKG. <br /> apacity PKG. TREATMENT PLT. ❑ ' <br /> p it <br /> Distance to nearest: Well Foundation Pro art t ' <br /> N JOA UIN M NTY <br /> LEACHING LINE ❑ No. & Length of lines Total lefnlejtl � <br /> FILTER BED C] Distance to nearest: Well Foundation �'PTb� ine <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS CI 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, a d <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "t 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 C i rnia." <br /> The applicant st call f r vire ions. Complete drawingZ-Ayl <br /> ers side. <br /> Signed Tide: Date: 'It✓ <br /> DEPAR <br /> Application Accepted by Date <br /> Are <br /> Pit or Grout Inspection by Date Final Inspection by Dais-1* <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IyF(yE AMOUNT DUE AMOUNT REMITTED C1C RECEIVED BY DATE PERMIT-NO. <br /> EH13-i�-26 25)REV.i/H- <br /> EH 1v / � /] ]?,� <br /> -- <br /> ✓ -J ((/ t�G <br />