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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 /> PERMIT XPIRES 1 YEAR FROM DATELLqaM <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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job Address rr+'y, _ City � '`� 1.t Size/Acreage 12 IN <br /> .��� ! � � � � �+ <br /> i <br /> Owner's Name , .A '� Address -- Phone <br /> O� S W License No. <br /> Contractor �\� Address li ���� - ��`-- -Phone <br /> TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out or Service Well L1 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well €� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE T�PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private 'D Gavel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done, <br /> Well Destruction ­ ❑ Well Diameter Sealing Material & Depth t� <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION & DESTRUCTION I I (No septic system permitted if public sewer is o <br /> available within 200 feet.) <br /> Installation will serve: Residence 1_ Commercial Other <br /> - --Number-of-iiving traits: --L-- Number-of-bedrooms- --- - p //u,A l� <br /> Character of soil to a depth of 3 feet: ��a+��^�"'4 t4 f -.-Water table depot <br /> SEPTIC TANK. D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property LineA IF <br /> " <br /> LEACHING LINE No. & Length of fines �' � �o Total length/size <br /> FILTER BED ❑ Distance to nearest: Well�2y Foundation 3!�? r Property Line <br />! SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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." Contractor's hiring of 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 California." - <br /> The applicant ust call for re wired inspections. Complete drawing on reverse side. y <br /> Signed Title: ku' C.+` Date: <br /> R ENT USE ONLY <br /> Application Accepted by hdinb <br /> Data <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by� '" —-- Dat�� ! <br /> Additional Comments: <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 AMOUNT RUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. <br /> INFO l ,�l CASH C� '] E <br /> . EH!}24 TREY,i1NSI V 1 �Y lb� t � J'P�J �� �� �c <br /> EH 14.26 11 <br />