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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 BOR 2009, STOCKTON, CA 95201 <br /> HERMIT EMRES 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 /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin-County Public Health Services. �/ <br /> Job Address City Lot Size/Acreage <br /> _ r <br /> Owner's Name eM 5ZR,01f(r Address 23 Ll e AM97- (CPO A) Phone <br /> Contractor ,Qi.L.< rvGLi`►2 Address 4O 14' ' !'t%G <br /> /—�-• — License No. Phone <br /> W <br /> TYPE OF WELL/PUMP; NEWELL'❑ WELL-REPLACEMENT-Q• _ DESTRUCTION.0 Out of.Service,Well D <br /> r <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTUR' E WELL OTHER WELL PITS/SUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I-1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> f`I Public f-1 Other 1­1 Delta Depth of Groul Seal Type of Grout <br /> I ! Irrioation' ___Approx. Depth I I Eastern Surface Seal Installed by i <br /> Repair:Work Done D Type of Pump H.P. State Work Dane I <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> jI Depth Filler Material & Depth <br /> ' a . <br /> TYPE OF SEPTIC WORK: NEW INSTALLA ION 9 REPAIR7AADDTTION-1 F DESTRUCTION1 T-(No septic system permitted if public sewer <br /> " x I avai4able within 200 feet.) t <br /> S Installation will serve: Residence ' Commercial_ Other <br /> Number of livirig units: __L_ Number of bedrooms <br /> ` Chaiacter of soil to a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK © Type/MigCapacity No. Compartments j <br /> PKG. TREATMENT PLT.- Method of Disposal <br /> Distance to nearest: WeIIAZ�— Foundation ZL'2Z_ Property Line <br /> LEACHING,LINE No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: __! __C77__ <br /> Well ( Foundation Property Line �o <br /> SEEPAGE PITS 11 Depth Size Number <br /> 1 r <br /> SUMPS • ,L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL kNDS 0 <br /> I hereby certify that I have prepared this,application and that the work will be done in accordance with San Joaquin county ordinances, itate laws, and <br /> rules and regulations of the San Joaquin' County <br /> Home owner or licensed agent's signature certifies the following: "Icertify 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 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 California." — <br /> The applicant must call for all requu ed inspections.'Complete drawing on reverse side. <br /> Signed L_45?__ ' Title: " <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area ,a <br /> - Pit or Grout Inspection by <br /> Data Final Inspection by ate 6 7 <br /> Additional Comments: <br /> ^� <br /> Applicant — Return all copies to: San Joaquin'County Public Heal <br /> Services, Xavironmental'Health Permit/Services <br /> .. 1601 E." Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT DATE REMITTED CAS <br /> INFO H RECEIVED Fit PERM17'ND. , <br /> / <br /> • EH14-24(REV.v/'Hs! �• L! C i/(`� _ _ �- 1 IS <br /> EH 94.20 F <br />