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APPLICATION, FOR PERMIT <br /> f 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 /> EXPIRESIT 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 /> spplicntioa le trade in eoraplianct with Ban Joaquin County Ordinance Ro. 549 and 11362 and yhealesand Regulations of San <br /> Joaquin County Public Health rvices. <br /> Job Address } City Loe/Acreage �^ <br /> -s Ngo`eF et%fvSme- 'r_ (Y\A1-y"LJ) Address7s \- Phone <br /> v ��,�,r�� - r, <br /> �" &�c:��� 37IL-Z 3��-SIS <br /> ContraoLti Address s _ _License No. Phone <br /> GTYPE.OF"WELD/PLJMP:/,fCA-',r,,/— MEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C ' r" OTHER 0 j, Monitoring Well C7 <br /> DISTANCE TO NEAREST:rSEPTIC TANK SEWER-LINES---------��ISPOSAL FLO. - PROP;LINE <br /> FOUNDATION AGRICULTURE-WELL OTHER WELLS <br /> PITS/SUMPS <br /> iJ,jj tNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFIGATIO_NS <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Diii'of Well Excavatiorf` Dia. of Well Casing <br /> Cl Domestic/Private ❑Gravel Pack ❑ Trac T ' <br /> Y Type of Casing �"�-� g t <br /> pecifications <br /> I'1 Public �Z'T�Other F1 Delta �"'-iyp4 of Grout <br /> I I Irrigation _�Approx. D'epth'�,.1 I Eastern Surface Seal Iftstelled by L + <br /> Repair Work Done U Type of Pump . <br /> H.P. <br /> H P State Work Done — <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material'& Depth <br /> Depth Fills Material & Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITI ONX DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.i <br /> Installation will serve: Residence Commercial Cher <br /> Number of living units: Number of b o ms ~`. <br /> Character of soil to a depth of 3 feet: Water table depth t ` <br /> SEPTIC TANK Type/Mfg Capacity _,&Ia. Compartments I <br /> PKG. TREATMENT PLT.❑ t C ( r 'elM_ethod of Disposal <br /> Distance to nearest: Well J� <br /> � Foundation 5 Property Line S <br /> � t <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance toynearest: Well Foundation Property Line <br /> i <br /> 4- <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPSLI Distance to -� <br /> nearest: Well <br /> DISPOSAL PONDS Foundation Property Line <br /> ❑ <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 r <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 Califorltia; ContracSo.r's hiring or sut}c_ont[acting-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." t <br /> The applicant t Cell }txmr) <br /> inspections. Complete drawing`o raver"sid J 1� <br /> Signed'x - — Ttle: V 'I - - — "Date: C23 <br /> '] � FOR <br /> "DEPARTMENT USE ONLY y� <br /> Application Accepted by Date J li*� Are L <br /> Pit or Grout Inspection by Date Final Inspection by (—t—!�-„ SLG Cmc Date � � <br /> Additional Commenter: <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 +1 <br /> FEE AMOUNT DUEAMOUNT REMITTED K j DATE 9NRECEIVED BY PERMIT NO. <br /> INFO CASH •� <br /> • fM 7t-M f11fY. /nSl —7n <br />