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APPLICATION FOR PERMIT A)p <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)4683420 j <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I 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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County ?P,ublic Health Services. �t��,q'� (� <br /> Job Address Z✓ Z `�`��� City 4 C Lot Size/Acreage 3/ /_5$t e;jl <br /> Owner's Name '6s5 Aloksr^qyw Address ` `�"' o {-�" "'e' Phone <br /> Contractor a!E 4*t,%e_ddress 70,5 tNmGeoye 41 `Dense fro dr,1d72 Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C) Domestic/Private Cl Gravel Pack L7 Tracy Type of Casing Specifications <br /> l'I Public 1-1 Other rl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —,.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 ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION/(No septic system permitted it public sewer is r <br /> available within 200 feet.) <br /> -Installation will serve: Residence-;�.. Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 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 Califor 'a." <br /> The applicant all for spections. omplete drawing on reverse side. <br /> Signed Title: Z. Date: -7 ... ~W <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 Area _ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> t <br /> Additional Comments: t <br /> f <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 95201CK 9 <br /> INFO AMOUNT DUE AMOUNTIR�EMITTED CFEE ASH RECEIVED BY DATE [�� PERMIT'NO. <br /> + EH EH 1/.�IREV.1/"51 S P pv 7 I..v� t i L Cl L� <br />