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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FR M DAIR IaSUED <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 PublicHealthServices. <br /> Job Address 1��`' <br /> City Lot Size/Acreage <br /> Address <br /> Owner's Name�1� fit[ SAy�M _ �- n <br /> �.�, �� (y(� <br /> ,.I ;'Phone .��--•- <br /> -.Contractor l� A v A- -Address i2�CRf r Z rz LicensePhone--M- <br /> TYPE <br /> OF WELL/PUMP: T NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - FOUNDATIONr,' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WJs.we, <br /> ll C <br /> ?. <br /> 1-1 Domestic/Private.. 0 Gravel Pack ❑ Tracy Type of Casing Specificat <br /> I'1 Public i-1 Other n Delta Depth of Grout Seal Type of G <br /> I-I Irrigation „Approk. Depth ' I I Eastern Surface Seal Installed by I <br /> Repair Work Done L] Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Wel! Diameter Sealing Material 6 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitt <br /> < available within 200 feet.I <br /> Installation will serve: Residence -- Commercial Other <br /> Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depthSEPTIC TANK ❑ T e/Mf �Yp g - � CapacityZ�, ,�,��CA No. CompartmentsI <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: -Well' � Foundation�� Property Line <br /> s mak., <br /> LEACHING LINE Cl No. & Length of lines ` L'oQ r otaf length/size:, 1- ?� <br /> FILTER BED ❑ Distance to-nearest: WellFoundation <br /> Q� Property Line <br /> J — _ <br /> SEEPAGE--PITS 11 Depth Size dumber _ <br /> �•.:ti <br /> SUMPS i LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS p ' <br /> I hereby certify that I hive 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 licensed agent's signature certifies the following: i certify that in the <br /> employ an work <br /> Y performance of.the work for which this permit is issued, I shall not <br /> p Y y 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 personsaubjecrto workman's compensa <br /> tion laws of California." �. <br /> ­.,.Theapplicant rp4st call for all req 'red inspections..Complete drawing on reverse side.. <br /> Signed �` W <br /> r Title: <br /> Date: _ <br /> R DEPARTME T USE ONLY sa C� tt E <br /> Application Accepted,by ` Date �` 1 <br /> Area <br /> Pit or Grout Inspection by q <br /> Date Final Inspection by Date S <br /> Additions! Comments: <br /> Applicant - Return all copies tot San Joaquin county Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTEDCK <br /> INFO GASH RECEIVED BY DATE PERMIT'NO. <br /> r EM 13-24(REV.I/H Sl j (� <br /> ftf 14.2e "tJ rJ� �JfJ <br />