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APPL I CATION FOR PERM I T'r' <br /> ,���}P '1 j sh r Ylr Jt <br /> SAN JOAQUIN- CQUNT7 PII$LICir HEALTH'.ft t ICES ' "�I� <br /> ENVIRONMENI,AL ,HEAL`BH, DIVISION ! <br /> 1601 E, "HAZELTON AVE. ,`.PHONE (209)468-3420 <br /> P' O BOX 1009 -STOCKTON� ' CA 95201 .R ''�` :t <br /> ' PERUIT EXPIRES 1f YEAR FROM DATE ISSITED r I <br /> (Complete in Triplicate) <br /> f., Applicatios, ie' 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 Services. 1 f <br /> 4L�D ��A��t—� L-� City Lot Size/Acreage <br /> _.' .fob Address_ r <br /> Owner's Name: 1�rCT AN Address Ltd S Phone <br /> Contractor . Aft L T Address ' r ' icense No.�i Phone <br /> TYPE OF WELL/PUMP: NEW WELL. 0 WELL-REPLACEMENT ❑ DESTRUCTION C) Out of Service Well. 0 <br /> PUMP INSTALLATION E) SYSTEM REPAIR _ ' '07HERY C -; Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD. f PROP=-LINE <br /> FOUNDATION AGRICULTURE WELL `OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE - _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0':Industrial i C1 Open 66ttom _-❑ Manteca '":Dia. of 1Neil Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing t Specifications <br /> I Public F I-1 Other n Delta Depth of Grout Seal Tye of Grout T. <br /> ! 1 Irrigation r T..Approx. Depth t I Eastern Surf ce Seal Installed by <br /> Repair Work Done:' :U:�Type.,of Pump rr H.P. r _r__- _.__ State Work Done <br /> Well Destruction , .f 0 F "Well Diameter Sealing Material & Depth h <br /> Depth IffA ,Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION 1 1 DESTRUCTION l I•1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence CommercialOther <br /> Number of living'units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK' O Type/Mfg g i -Capacity F No. Compartments <br /> �tN <br /> PKG. TREATMENTjPLT;❑ �; Method of 6isposal v <br /> Distance to nearest:• Well Foundation Property Line f .F' <br /> LEACHING LINE ElNo. &,Length of lines Total leri gth/size <br /> FILTER BED f n Distance to nearest: Well Foundation _ __ -_ __ Property Line N, <br /> A, <br /> SEEPAGE PITSI I Depth Sire Number <br /> SUMPS", UI Distance to nearest: Well Foundation .*� Pro <br /> party-Line <br /> DISPOSAL PONDS; 0 <br /> r <br /> I hereby certify that;) 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 ficensed agent's signature certifies the following: "I'rcertity-that in the performance of the work forawhich this permit is issued; I shall not, <br /> employ anyperson such manner as.to become,subject to workmen's compensation laws of California." Contjcior's hiring or sub-coniracting,signature <br /> certifies the fotlo Ing "I 4. <br /> certify that in the performance of the work for which this permit is issued,J_shah employ persons`subject to workman's'compenss- ' <br /> tion laws of ;.I <br /> The applicant $call for all re it inspec o s.�Comrpletl,drawing on re era sde. I <br /> Signed X Title: Date.. -d <br /> FOR EPARTMENT USE ONLY_ <br /> Application Accepted by Date <br /> P.it..Qr_Grout,.lnspection_by,: - — •"` _ -Oate-...—i,-----_-�-•-Fine)-Inspection-by <br /> Additional Comments: <br /> Applicant - Return all copies,to: San Joaquin County Publi kealth a <br /> Servic`es;,Environmental.Health Permit/Services ra c t <br /> 1601 E. Hazelton <br /> Ave..-­Ii O'Sox 2009,'Stockt6n ,`'�R" 95201` ) <br /> ,FEE 'AMOUNT DUnATE <br /> E <br /> REMIT EC(.,.-. � 'CK - „ �R <br /> JRCASH_-INFO <br /> - <br /> EN 13-24 IAEV. <br /> EH:4.211 t t L IBJ <br />