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. 3 � <br /> 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 BOX 2009, STOCKTON, CA 95201 <br /> p IT EXPIRES- 1 YEAR FROM DA E ED <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This i <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 /> 5Lot size/Acreage <br /> /Aeage / " �1�> <br /> Job Address G �'� City �//✓.�� x <br /> Owner's Name <br /> f,Q/S /FP�SdIt7 Address Phone d <br /> ,r -- <br /> pp <br /> Contractor, Address License No. <br /> 3tPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> Monitoring Well PUMP INSTALLATION C3 SYSTEM REPAIR 111 OTHER ❑ <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 IJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Type Specifications <br /> I'1 Public t C3 Other n Delta Depth of Grout Seal Type o} Grout <br /> I I Irrigation —Approx. Depth t I Eastern Surface Seal installed by 9 <br /> State Work Done Sta _ <br /> Repair Work Dane ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter _._. ---- <br /> Sealing Material & Depth r� <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADOITION MM' DESTRUCTION I I (Nosepti cystithin m rented it public sewer is <br /> avainstallation will serve: Residence� Commercial_ Other <br /> Number of living units: __L_ Number obedrooms r d 1 <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments e <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> tO ' <br /> LEACHING LINE LA No. & Length of lines ,/ — Total length/size <br /> FILTER BED Cl. Distance to nearest: Well Foundation _ Property Line <br /> 7 <br /> SEEPAGE PITS lW Depth �� t Size Number! <br /> SUMPS 0 Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ k <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 a <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 req red 'nspections Complete drawing on reverse side. , <br /> Signed X Title: 040A rDate: 11-17-F47 <br /> FOR DEPARTMENT USE ONLY �G <br /> Application Accepted by <br /> YY� Date } Area Z 13 <br /> \ L <br /> 1 it ob <br /> r Grout Inspection –� Date;� Z t zcJ Final Inspection by 'r –��� Date �� <br /> 3 <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 /> IFEE <br /> N O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> I y,O �-r,v u z, 11-z�-� <br /> l r EH 1321 IRSV.1�x 51 <br /> 1[ EH 14.20 <br />