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T� Y *� 57- 1 r 2� 3 '.£trsf-s%"r(J <br /> r APPL I CATION FOR PERMIT 9/2s190 j 7D 99.86 ; <br /> 9y,Y4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI SSS ,••a.:. I 91.Gr <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EBPIRES 1 YEAR FRQM DATE ISSU—ED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cot 'liance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> r Joaquin County Public Health BeAices. f <br /> _ City (� Lot Size/Acreage <br /> Job Address / <br /> Phone ` C'� <br /> Owner's Name &&ddress <br /> v/&rY CA013 31ly <br /> c+5 7- syssys � c <br /> Contractor I AddressLicense No. Phone <br /> TYPE OF WELL/PUMP: il; NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTE EPA1R 0 OTHER D Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.� PROP. LIN{E ' <br /> FpUNDATION AGRICULTURE WE L OTHER WELL PITS/SUAPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI0NS ` <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excav .o ]� Dia. of Well Casing <br /> Vf-Bomestic/Privateravel Pack O Tracy Type of Casing V SRecificattons <br /> 1'I Public <br /> J'OG <br /> tter (J Delta Depth of Grout Seal o- (a Type of Grou0t!!��� <br /> I I IrrigationQ..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth �•y <br /> Depth Filler Material & Depth S <br /> TYPE OF SEPTIC WORK: .W INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence— Commerdial— Other <br /> Number of living units: L Number of bedrooms i <br /> Character of soil to a dept hf of 3 feet: Water table depth <br /> SEPTIC TANK. O ` Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PET.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 I No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 I Depth Size Number <br /> y <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line t -0 <br /> DISPOSAL PONDS ❑ ! t <br /> I hereby certify that I 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 licensed ageni's signature certifies the following: "I certify that in the performance of the work for which this pert it is issued, I shall not <br /> 4. <br /> employ any 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 persons subject to'workman's compensa- <br /> tion laws:of C rnia." <br /> The applica s�tca`lf mall r wired in tions. Complete drawing on reverse side, 9 <br /> Signed X <br /> ' FORD AAT SE ONLY <br /> Application Accepted by <br /> Date Are <br /> Pit or Grout Inspection by Z, Date ` Final Inspection by Date .a G <br /> Additional Comments: - <br /> .y <br /> Applicant - Return all copies to: San Joaquin County Public Health II <br /> Services, Ettvironmental'Health Permit/Services I' <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> C, <br /> INFO AMO NNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PER MIT'NO. ` g <br /> 2/ 1 <br /> , EM1344[fill. si � <br /> EH 14.28 __till <br />