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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 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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 Health Services.I Job Address "'r _ J'w' , ! r City �11 Lot Size/Acreage �r <br /> Owner"s Name 1:5 , ' Phone <br /> Contractor <br /> j Address . License No. Phone3 <br /> TYPE Of WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �l Out of Service Well ❑ <br /> C <br /> PUMP INSTALLATION 13SYSTEM REPAIR L7 OTHER J Monitoring Ftell U <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1.1 Domestic/Private 13Gravel Pack La Tracy Type of Casing_._ Specifications <br /> I'! Public Cl Other F"1 Delta Depth of Grout Seal Type of Grout <br /> i s <br /> 11 Irrigation 1 Approx. Depth I I Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Welt Diameter Staling Material & Depth <br /> Depth Filler Material & Depth <br /> �j <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION 1 1 REPAIR IADDITIONDESTRUCTION I I INo septic system permitted it public sewer is v <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. C1 Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT.D i Method of Disposal <br /> e Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE � No. & Length of lines /— Total length/size n <br /> FILTER BED ❑ Distance to nearest: Wall � oundano Property Line O <br /> 1} <br /> 1 SEEPAGE PITS 11 Depth� Size _ Number <br /> i SUMPS LI Distance to nearest: Well Foundation Property Line <br /> j DISPOSAL PONDS ❑ y /a <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, andli <br /> k rules and regulations of the San Joaquin County //(� <br /> Home owner or licensed agent's signature certifies the following: "J certify that in the performance,of the work for which this parmit 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: "1 certify that in the performance of the work for which this permit is issued, I shah employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The:pplicantast.call for all r tied inspections. Complete drawing onrereeverse side. <br /> L t i � �'S fl/40-77e/� Date:Signd X -J �. Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �U �� �L Area <br /> Pit or Grout Inspection by Date Final Inspection by •i �,?n CJ,�r\ Date <br /> Additional Comments: `r4`�� t�'�=�//nRn e �dc� fi� //^e Leat fs !6e rP� <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 /> FEE iCK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 IREV.I/H S [/ /• Y /� {(14 ;�`� 1'�' 13 .� <br /> EH 142rs t\ l IJ <br />