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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PAYMENT <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> PF"IT EXPIRES 1 YEAR FROM DATE ISSUBn MAY 2 9 19% <br /> (Complete in Triplicate) SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or instaLIE1MOWBAfALrHwi}iowi$IQNis <br /> application is made in compliance with-,"San Joaquin County Ordinance No. 549 andel 1862 n the Rules and Regulations of San <br /> Joaquin County(-A'A Public�C—* C4:W V%W Services t4 5 tAt.� T vy c �,� V <br /> Job Address _ � W-6• chf'~w' �/1y5�Gii�r'+ City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> FAylrko <br /> Contractor JU <br /> dress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER�� M� Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 !�rF SEWER LINES 9 100 tDISPOSAL FLD.� PROP. LINE rn <br /> ln l <br /> FOUNDATION AGRICULTURE WELL 2 id] OTHER WELL�t PITS/SUMPS <br /> INTENDED USE -NIA TYPE OF WELL�I PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Jw �nr_hes Dia. of Well Casing <br /> C❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> 0 <br /> I I Irrigation ._•_,Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H-P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth 15--2.19-7 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIWADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will some: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total Length/size <br /> FILTER BED •L /f?� Cl Distance to nearest: Well 7101 Foundation a f� } Property Line <br /> SEEPAGE PITS tI I Depth Size Number <br /> SUMPS I`sA LI Distance to nearest: Well >IQ& Foundation ­'>102! Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and �7 <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 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." Contractors 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 Cali Is <br /> The applica us call for a fired inspections. Complete drawing on reverse <br /> -_side. <br /> Signed Title: l?R.�S tAF� &4R . Date: S <br /> OR EPARTMENT USE ONLY <br /> Appli tion Accepted by Date r / �� Area 42 G <br /> Pit or Grout Inspection b Date �Final Inspection by Date <br /> w. I aL� `t )I <br /> lt? <br /> Additional Comments: y r <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED r RECEIVED BY DATE PERMIT'NO. <br /> . EH 13.24(REV,i/As13►• D� �[ t""' l_�]�Ji"` (, ��•' 1 ! /J <br /> .aEH�E4.2E� t�I r <br />