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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 /> EXPIRES 1 YEAR FROM <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 /> n <br /> application is made in with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Healt}h� Services. �Y <br /> Job Address r^� �f'�l City f Lot Size/Acreage .+[ <br /> Owner's Name _ t . . r L - eAddress Phone q �. c�+� .Z�" ! . U <br /> - <br /> Contractor 1 i s'=� * ' �G Address ` `•✓i 0�`! �1. License No. ^M � j" phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT E:) DESTRUCTION ❑ Out of Service Nei Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR D OTHER ❑ Monitoring tire) [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ��. I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-) Industrial 11 Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack E7 Tracy Type of Casing Specifications <br /> I't Public C1 Other 171 pelta Depth of Grout Seal Type of Grout <br /> _- <br /> I I kriUation _.Approx. Depth I I Eastern , Surface Soul Installed by I <br /> Repair Work Done 0 Type of PumpH. '�' ^ 1 <br /> State Work Done <br /> Well Destruction 0 Well Diameter ----_-_.� Scaling Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION If REPAIR/ADDITION I r DESTRUCTION I I (No septic system permitted it public sewer i� <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_�,{hher is ! is <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet '1 '=} Water table�1depth <br /> SEPTIC TANK. D Type/Mfg 4 Capacity__ z No. Compa(tmen4 <br /> PKG. TREATMENT PLT. ❑ Method of Qi Deal +� <br /> Distance to nearest: Well 1, _ F undatiort Property Line I—. _ Ih <br /> LEACHING LINE Or No. & Length of lines _„■z. -_- __�_ ` �Er4tal length/size <br /> FILTER BED 0 Distance to nearest: Well 1 Foundation'Property Lina <br /> r <br /> SEEPAGE PITS I Number <br /> 1 Orth Size _ _ } , <br /> ,. �� ' • <br /> SUMPS ' l_I 4istance to nearest: Well Foundation Property <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo�lquin F4linty ordinances, state laws, antj <br /> rules and regulations of the San'Joaquin County s <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for ich his permit is issued, I shell notes <br /> employ any person in such manner as to become subject to workman's compensation laws of California.';Contractorls hir g or sub-contracting siq�ature� <br /> certifies the following: "1 codify t at in this rformance of the work for which this permit is issued, i shalt am Io erso s subject to workman's compensa- <br /> tion laws of California."` r <br /> The applicant II for a"I gVired irt�pactions. Complete drawing on reverse side. ` <br /> Signed i"� t Title <br /> nate: <br /> tF ! NT USE ONLY <br /> Application Accepted by ate <br /> - Area <br /> Pit or Grout Inspection by Date Finallhapectiop by Date <br /> Additional Comments: a'T -- to r _d <br /> Applicant - Return all copies to: San Joaquin County Public,,#palth <br /> Services, Environmentel;11ealt� Permit/Sere;ces <br /> 1601 E. Hazelton Ave., P"•O"Box 2009, Stockton• CAFEE 5201 <br /> INFO AMOUNT RUE Ab'Oq R NI TTEDM _ �. CK L* RECEIVED BY , RATE PERMIT NO. <br /> . EH 13.24 1REV.r/K51 f." r <br />