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r 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 0 BOX 2009, STOCKTON, CA 95201 <br /> PIRMIT EXPIRES 1 YEAR FROM DATE 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. 5119 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage a ZqC <br /> Owner's Name (�tQ1PAnr1CA- Address Phone <br /> I <br /> Contractor Address License No. 3C�J'11 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> x <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 /> D Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ! Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications IX\ <br /> Il Public 1-1 Other n Delta Depth of Grout Seal t Type of Grout ; <br /> I I Irrigation .-w,..Approx.'Depth I I Eastern Surface Seal Installed by % �{ • ; O <br /> Repair Work Done 0 Type of Pump H.P. State Work Done" I <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material 6 Depth III <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION i I DESTRUCTION l II(No septic system permitted it public s Ower is <br /> available wiihin 200 feet.) <br /> Installation will serve: Residence Commercial �,. Other <br /> Number of living units: --I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: _S Prn D .Water table depth f ' <br /> SEPTIC TANK <br /> @- Type/Mfg Capacity/ No. Compartments I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal j <br /> Distance to nearest: Well /A� Foundation� P operty.Line ' <br /> f- y <br /> e <br /> 1 i <br /> LEACHING LINE I- No. A Length of lines r-0 r ti Total length/size 1 f <br /> FILTER BED C7 Distance to nearest: Well jLM Founda"tion—_S_D . .Property LineYy <br /> SEEPAGE PITS t4 Depth _Size_ _ Yc�' r 4 ~ Number - <br /> SUMPS LI Distance to nearest: +f Well Foundation� Property`Li e, -,ZZ5 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this.application and that the work will be done in accdrdancee with San'Joaquin county ofdinances,state laws, an <br /> rules and regulations of the San Joaquin}County .'•,,� t (I <br /> ! <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the peRorinance�af the wa►k for which this permit is issued, E shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Ca)ifornia."Coiittactor's hiring or sub-contractirig signature <br /> certifies the following: "I certify that in the performance of the work for which thispermitis issuedtf-shalhmpfoy- <br /> tion laws of California." persos subject to workman's compensa <br /> r r ` h. <br /> The applicant must c 71,11 <br /> all required s ions. Complete drawing on reverseide. <br /> t r <br /> l� <br /> SignedX._._� . _ Title:-�. _'ADL-t2Yl tE:� -- Date: <br /> i s k s A ' <br /> FO DEPARTMENT'�USE ONLY 1` ; <br /> Application Accepted by A Ad °pate_ - —Area. <br /> 'for Grout Inspection by% Date 2 -Final Inspection by z L, Date / <br /> Additional Comments: <br /> Applicant - Return all copieweio: San Joaquin County Public Health , <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IEEE AMOUNT DUE t AMOUNT REMITTED K H R EIVED BY DATE PERMIT NO. <br /> + EH13.24(REV.t 511 j A2- <br /> / , <br /> EH 14-26 ii <br /> =ti <br />