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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ND <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. <br /> Job Address C• 'Ai:; `/ dor City S lot Size/Acreage <br /> Owner's Name � d��E�r� Address _/ I (`AC, r gA AS-WL1G e D� Phone <br /> C ntraolof 1A C i�� Address ' (tq �L <br /> ' License No. 'Phon,� <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OT Monitoring Well . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D LD. PROP. LINE <br /> FOUNDATION AGRICULTURE W OTHER WELL r PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBL A CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private 0 Gra ck 0 Tracy Type of Casing Specifications <br /> I.1 Public Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Rep ' ark Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I ) DESTRUCTION (No septic system permitted if public sewer is <br /> -available within 200 feet.) <br /> Installation will serve: Residence-Z Commercial_ Other <br /> Number of living units: —L— Number of b rooms <br /> Character of soil to a depth of 3 feet: J- 1� Water table depth M <br /> SEPTIC TANK © Type/Mfg ,6tCr__ __ Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. 0 Method of Disposal i <br /> Distance to nearest: ^Well_'Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well, Foundation Property Line <br /> y <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O t <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 QZ <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 C <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 comp ansa` <br /> tion laws of California." <br /> The applica ust call for al requir inspections. Complete drawing on raver[[� <br /> Signe ti Title: __ Cil [ Date: <br /> R DEPARTMENT USE ONLY i y <br /> Application Accepted by C"ne,� „ L _ _ Date 1 `� Area <br /> Pit or Grout Inspection byDate Final Inspection b Data �y 6 <br /> Additional Comments: <br /> Applicant - Return a.11 copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUEAOUNT REMtTTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-M IREV.1/X Sl � �0-0 � � jt Q � r 1 1] <br /> EH t3•Ze (J (J 0 +1 <br />