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h <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 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRPM DATE issum <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 �� -Ci -fL � /!/�/�/CSC Cit ^ Lie/Acreage Z <br /> Owner's Name Address Phone <br /> i <br /> ,/ 4 r <br /> ContractorA L �— Addres / License N4�jf /c, Phone <br /> TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> I��� ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _- <br /> FOUNDATION <br /> FOUNDATION AGRICULTURE WELL "—"— OTHER WEL�_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `oo � <br /> n industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casin lW I <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> f'I Public fa Other n Delta Depth of Grout Seal T e Grout r <br /> 1~i Irrigation ,_.._-Approx. Dees th I i EastEVn Surface Seal Installed by Met seve <br /> Repair Work Done 0 Type of Pump,71/ �/l6.P. �:2� State Work Done .._ t <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence _ Commercial— Other <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ _ Method of Disposal <br /> + Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 DepthSize _ Number a I <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <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 j <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 taws of California." <br /> The applicant must call for all requi ed inspections. Complete drawing on rave a ids. <br /> Signed Title: A G y Date: <br /> 4 EPART EMT USE ONLY F <br /> Application Accepted by ■`� -Date. s_■?. L <br /> -- ^ Area <br /> _ <br /> Pit or Grout Inspection by Oats Fina spection by Dat <br /> c 4 <br /> Additional Comments: kb*- A P_r- "X <br /> Applicant — Return all copies to: Se.n -in County Pu is Health 8S r <br /> Services, Environmental Health Permit/Services 7 ' <br /> — 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEINFO AM VNT ptJE AMOUNT REMITTED CASH RECEIVED BY DATES l <br /> PEAMIT'tNO. <br /> • EHt�.�tREy.tiKsr 15 I4 f a1— IL <br /> v A1 _Ilfl� <br />