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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNEINTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EMIT EXPIRES 1 YEAR FR9—M DATE 15SUBP <br /> 1J (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 Servic <br /> q , p <br /> Job Andress —8 � r — Cit Lot Size/Acreage <br /> ` , <br /> n. _ f , � I <br /> }'Address ? Phone <br /> -O;wner's NameA�—" � n „ <br /> ......_,.�..--.7 n- -./E may..,.....S License No Phoneq <br /> Confiractor ©`! Address r a <br /> v7YPE OF WELLIPUMP:`,f NEW WELL ❑ ELL REPLACEMENT'D `DESTRUCTION o Out of Service Well G1 <br /> 1". OTHER O Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM AIR.❑ 4; <br /> ., r <br /> DISTANCE TONEAREST: SEPTIC TANK SEWER LI 5 DISPOSAL FLD. PROP. LINE <br /> F FOUNDATION AGRICULT E LL OTHER WEL-L� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFiCATIDNS <br /> P Industrial 0 Open Bottom-�- �7.Manteca a. of WeEI Excavation Dia. of Well Casing <br /> _ <br /> Cl Domestic/Private { Cl Gravel Pack ❑ Tracy YET pe of Casing,. m. t Specifications <br /> I'1 Public 1-1 Other Cl Delta D pth of Grout Seal 4 Type of Grout L <br /> I I Irrigation f _.Apprax. Depth l I East S dace Seal installed by <br /> Repair Work Done ' ❑ Type of Pump H.P. I State Work Done z <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth- "( <br /> Depth Filler Mater i Depth vY , <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION I 1 REPAIRIADDITIO14 { . DESTRUCTION l I (No sepiic.system.permittMd if p tblic sewe is ' <br /> available within Wfee 4 . <br /> 0 <br /> Installation will serve: Residence Commercial._ Other _ f tNumber of living units: Number of bedroo s ' - •> v ` <br /> _ ^t y <br /> Character of soil to a depth of 3 feet: W er I <br /> SEPTIC TANK. 0 Type/Mfg ' Capacit No. Compartments. <br /> Method of,Disposal <br /> PKG. TREATMENT PLT. ❑ T <br /> Distance t nearest: ell Foundati n Property Line r <br /> LEACHING LINE ❑ No. & Length of lines Total-lengt'h/size <br /> Pro --� ' <br /> FILTER BED ❑ Distance tc nearest: Well perry Line <br /> SEEPAGE PITS I I-^'Depthx 00' Size _ �u�mber � <br /> SUMPS LI Distance to ries est ., . Well oundation Property Line <br /> DISPOSAL PONDS Q <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 - - 4� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the-work fpr-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." CoAtractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the pertorrriance 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 applicantI st coil f required i spections. Complete drawing on reverse side.- <br /> 9 <br />` Si ned X f' Title: Date: <br /> ' OR.DEPARTMENT USE ONLY <br /> Application Accepted by Dat83 F Area <br /> Pit or Grout Inspection by ate Final-Inypep on y Date� 7 <br /> Additional Comments: <br /> Applicant - Return all copies to SaninCounty Public Health � <br /> Services,-Environmental Health Permit/Services r <br /> 1601 E. Hazelton-Ave., P 0 Box 2009, Stockton, CA, 95201 <br /> FEE AMOUNT Dill: AMOUNT REMITTED CAS - 4 ti RECEIVED BY DATE PERMIT'NO. <br /> INFO w <br /> . EH 13.241REV.I/h5t �" � v f � / / o a- <br /> y Eli 41.2E <br /> 4 -- <br />