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APPLICATION FOR PERMITt <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 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 <br /> bli/c'-Health Services. <br /> Job Address !E 1 /) � City Le' 4 Lot Size/Acreage <br /> Owner's Name ad a n Address 7` Phone <br /> Contractor IL&Y_40 Address I '��� License IVo.r Phone3 <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L1 <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 <br /> n Industrial Cl Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications <br /> I'I Public 1-1 Other Fl 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 0 Type of Pump _ H.P. tate Work Done _ <br /> p �� T Sealing Material <br /> II, <br /> G r <br /> Well Destruction Well Diameter ti <br /> __ � Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION i I DESTRUCTION € I lNo septic system permitted if public sewer is <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: able depth <br /> SEPTIC TANK ❑ Type/Mfg C aci aBod'mpartments <br /> 1 I <br /> PKG, TREATMENT PLT. 0 -7 of Disposal <br /> Distance to nearest: Well Found tin ¢ine <br /> rtmi�ma � ►', y' C1 [' <br /> LEACHING LINE D No. & Length of lines oinrt r,� ftl�il��t� . ��I�eng L- ` <br /> FILTER BED O Distance to nearest: Well fd"I lation '1 ?pp4joftine <br /> SEEPAGE PITS i I Depth Size UU1t'' 11 Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that l 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: "1 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 California." <br /> The applicant must callforall required i speptions,Complete drawing on reverse/side. <br /> Signed 1� / ?fA!f.d440An, Title: St'[�/ _ Date: <br /> T-MENT U ONLY <br /> Application Accepted by Date L 4 Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <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 /> INFOFEE <br /> AMOUNT DUE AMOUNT REMITTED CASH DECEIVED BY DATE PERMIT N0. <br /> . EH 13.24IREV.tin 5) a n1 1 i i j <br /> EH 14.26 ( 1 ` `NrJ <br />