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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 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR PRO RATE ISSUED <br /> - (Complete in Triplicate) <br /> Application is hereby made,to San Joagx;in, 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. / -Sd4zalo <br /> Job Address G" City/19 VO-K)- - )ot Size/Acreage <br /> Owner's Name Address Phone' <br /> Y Cantraclor T,�.f s G.. /�-�IQi r Address ��. - '� / License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER © Monitoring Well Ea <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ,I i'l 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 /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t'l Public 1:1 Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 litigation —Approxi-Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type_of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION74 REPAIR/ADDITION I I DESTRUCTION t I lNo septic system permitted if public sewer is b <br /> ,/ available within 200 feet.) <br /> installation wilt 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 /> --::R <br /> SEPTIC TANK ❑ Type/Mfg'- '' Capat ity�2 No. Compartments <br /> PKG. TREATMENT PLT.Cl i j : fT 1 Method of Disposal ` <br /> Distance to nearest: Well Foundation Property%Line �Y <br /> LEACHING LINENo. & Length of lines r "`" T Total length/size r \ <br /> FILTER BED C-I Distance to nearest: Well/� Foundation _A0 Property Line <br /> SEEPAGE PITS I I Depth _Z/3 /f' Size �Z >��ZZ ---7-Number ' <br /> 'SUMPS ')0( Distance to nearest: Well M"" Foundation rte--`—-Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <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 laws of California." <br /> The applicant must callfor Zrad inspections,,Complete drawing on reverse side, <br /> Signed X / / Title: Dater <br /> OR D ARTME SE ONLY <br /> Application Accepted by Date s^ <br /> Pit or Grout Inspection by Date Final inspection by Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Realth Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> b FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. <br /> INFO CASH <br /> + EH 13-24tNEV.fits 5) C7a ' ►m,� �.�'. r,.� J t� '/ r �f <br /> EH 94•26 <br />