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f <br /> APPLICATION FOR PERMIT <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EN V,I RONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE: , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT E FIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sea Joaquin County for a permit to construct and/or Install the work herein described. Thi <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sar <br /> Joaquin County Public Health Services. <br /> Job Address /yyJf/� {/'J� �j Y tJ'O <br /> Gly �^�LLG- Lot Size/Acreage '\ - / <br /> a r < <br /> Owner's Name - ddress Phone <br /> Contractor R/--�—Address _ License Nol2� Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT [7DESTRUCTION ❑ Out of Service well <br /> PUMP INSTALLATION CI SYSTEM REPAIR 0 - Monitoring well r <br /> • `� �; OTHER L�� _ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. y PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial 0 Open Bottom "D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ('.I Dorrbstilt/Private CI Gravel Pack n Tracy Type of Casing_ Specifications — <br /> i'1 Public " ' .1 1 Other (1 Delta Depth of Grout Seal _ -_ Type of Grout <br /> I I Irrigation -__ Approx% Depth I I Eastern SUrfaCe Seal Installed by _ <br /> -tea Repair Work Done U Type of Pump H P State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> +` %* I Depth r •/ Filler Material L Depth- <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION If REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted J public sewer is <br /> � I r available within 200 feet l <br /> w\4� <br /> Installation will serve Residence �I Commerclef Other <br /> Number of Irving units: -I— Number of bedr oma <br /> Y Cf erecter of soil to a depth of 3 feet: _Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments -_ <br /> PKG. TREATMENT PCT. F' ` �/ LLLL Method of Disposal _ <br /> Distance to nearest: 'Well / Foundation s Property Line_ <br /> LEACHING LINE L1 No. & Length of lines <br /> FILTER BED' - CI Distance to nearest: Well. b_ Foundation_ �� Property Line '-'-1 f7 ` <br /> SEEPAGE PITS 11 Depth �� __ Number _ <br /> SUMPS LI Distance to nearest: Wtl Foundation 1��— Property Line _ �^ <br /> DISPOSAL PONDS O <br /> I hereby certify that I have prepared this application and that tho'work will be done in accordance with San Joaquin county ordinances, state laws, ar <br /> rules and regulalrons of lne San Joaquin County �( <br /> Home owner or licensed agent's signature certifies the following: ,1 certify that in the performance of the work for which this permit Is issued, I shad m <br /> employ any person in such manner as to become sublevt to workmen"a compensation laws of California "• Contractor's hiring or sub-contracting srgnatu <br /> certifies the following: "I certify that in the performance of 04 woihJor which this permit is issued, 1 shall employ persons sublect to workman's compers. <br /> tion laws of California." <br /> The applican :�/std(II II requu r spections. mp a drawing <br /> Signed X_?7' / �- - ��✓ Tale: - - -- Date: -7 FOR DEPARTMENT USE ONLY <br /> Appllc jon Accepted by _ Date 7, - �. Area <br /> bout In�4ion by Date ��Final Inspection by �2 Date ?` <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health _ _n <br /> Services, Environmental Health Permit/Services �v <br /> 1601 E. Hatelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMIT NO. <br /> A <br />