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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 0 BOR 2009, STOCKTON, CA 95201 _ <br /> g_ EXPIRES I. YEAR FROM PATE 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 1.862 and the Rules and Regulations of San <br /> Joaquin Cty PubLiH i h,5 rvic �1Job Address .� f��C'� t:)�- dd ?ity -tu Lot Size/Acreage <br /> Owner's Name �� Address Phone n <br /> j Contractor Address a'C-License No. r -� �� Phone `$tea <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-:] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION E3SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> _ <br /> iNT'NDED USE TYPE OF WELL PROBLEM AREA',, CONSTRUC4TIOf- <br /> N SPECIFICATIONS. <br /> L7 Industrial ❑ Open Bottom ❑ Manteca bia. of Well Excavation 1 Dia. of Well Casing <br /> i <br /> Cl Domestic lPrivate ❑ Gravel Pack C7 Tracy . ,T`ype of Casing------ Specifications <br /> F1 Public [I Other n Deita—� Depth of 6,6-UI Seal Type of Grout <br /> I i Irrigation __.Approx`Depth I I Eastern Surface Seal-installed-by z <br /> i <br /> Repair Work Done U Type of Purrip %H.P. € State Work Done _ <br /> w �•3..-4,t Sealing Material Depth"'"v <br /> Well Destruction D Well Diameter - � <br /> Filler Material &.-., <br /> Depth <br /> I Depth - _ - �.: :. <br /> TYPE OF SEPTIC WORK:�-NEW-INST"A ATION 1"I"''REPAIR/AOOITIO DESTRUCTION l I.INo septic system permitted if public sewer is <br /> � � ;available within 200 feat.] <br /> Installation will serve: Residence 4 Commercial x Others 1 I <br /> Number of living units: l - ryNumber of'bedrooms { i <br /> Character of soil to a dep!hof 3 feet: � ;'j""r-• - —Water table depthr I, <br /> SEPTIC TANK • €O Type/Mfg _�� J+ �n ��'���CapatitySNo.'Compartments <br /> PKG. TREATMENT PLT. ❑ ' i t 1 ! Method of Disposal �t- <br /> r ; 4. Distance.to nearest: ation Property Line 1"�� <br /> LEACHING LINE t ,fVo._&Length-of lines " Total length/s"iz"e <br /> FILTER BED Ll Distance to nearest: Well a1n 0 Property Line <br /> SEEPAGE PITS I I Depth 3 - Si, — Number <br /> jek Distance to nearest: r tt nda 40 1 Property Line <br /> DISPOSAL PONDS ❑ /T C>� <br /> I hereby certify that i have prepared this applica n.aAd that the work will be done " ccordance with San Joaquin county ordinances, state laws, and t <br /> rules and regulations of the San Joaquin Count ]y- t f <br /> Home owner or licensed agent's signature certifies the foilowing "I certify that in the performance of the work for which this permit is issued, I shall not f <br /> employ any person in such manner as to becomeJublapt,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 requ'ed 'inspections..Complete_drawing on reverse side. ' <br /> - 4 <br /> Sighed Title: __._ Date: <br /> =. R DEPARTMENT USE ONLY ` <br /> i �'�� 1 1 <br /> Application Accepted by _ `+r+ �� Date Ares <br /> 1 <br /> Pit oe Grout Inspection by Date Final Inspection by` Date�-2_2 ' <br /> Additional Comments: <br /> t <br /> Agplicaitt - 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 /> E. iNF� AMOUNT DUE OUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. j <br /> ♦ EH13-24tR2A? <br /> EV.tinSY L ��� z_ <br /> EH 14.26 1 <br /> t, <br />