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APPLICATION FOR PERMIT <br /> ,mow-�--• �_. <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P D BOX 2009, STOCKTON, CA 55201 <br /> pEMIT EXPIRES 1_ YEAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> Application la hereby made•to Sao Joaquin County for a persalt to construct and/or install the work herein described. This <br /> application is ,bade in Compliance vith San Joaquin County Ordinence No. 5h9 end 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. _ } <br /> JobAddress _ - A)�fJA�RI a c p=d City Lot Slxe/Acreagc <br /> Owner's Name {'1� 0 AddressIJO 70 E 1A)111d o-3 <br /> Conlractor K^ Addressr 'C� (SA/T License No Phone <br /> TYPE OF WELL/PUMPNEW WELL C. WELL REPLACEMENT DESTRUCTION C. Out of Service well ❑ <br /> T PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER/O bionitoring Well 0 <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.,e PROP- LINE <br /> FOUNDATON AGRICULTURE WELL' �OTHEW W'ELL Pf�SIStJN1P5`� <br /> INTENDEO USE TYPE OF WELL PROBLEM AREA CONSTR ILICT(ON SPECIFICATIONS r, <br /> n Industrial pen Bottom G Manteca Dia- of Wait Excavation. Dia. of WellCasing <br /> XDomesticlPriyate U Gravel Pack 0 Tracy Type of Casing ISpecifications <br /> t'1 Publk I'!l'O�thgf E-1 Della Depth of Grout Seal r____. r Typs roilt -''►k Gy <br /> I I Irrigation e�YDApprox. Depth 1 I I Eastern urface Sea$ installed by I P �+ LI I u 2 <br /> Repair Work Done U Type of Pump til] H.P.well Oestruction ❑ Well Diameter $e0.littg urittl i Depth <br /> Depth Piller Material & Depth i 5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE PA IRIADDITION1-i- pESTRUCTION I-I INo septic system permitted if public sewer is { <br /> .available within 200 feat.) I f!} <br /> Installation will serve: Residence— Commercial— Other = j I I <br /> Number of living trni=s: Number of bedrooms: <br /> Character of roil to a depth of 3 feet: Water tabl6 depth I <br /> SEPTIC TANK. ❑ Typal Mfg Capacity No. Compartfrtents �{ <br /> PKG. TREATMENT PLT.❑ Method of Disposal ~ <br /> r 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 IV C <br /> i 3 i <br /> SEEPAGE PITS I I Depth Size Number } 1 <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line �f <br /> DISPOSAL PONDS ❑ t t <br /> I hereby certity that i have prepared this application and that the work will W done in accordance with San Joaquin county o►dinances. state taws, ander 1 <br /> rules and regulations of the San Joaquin County , <br /> Horne owner or licensed agent's signature ceruties the loliowinT "I certify that in the perforrriance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become aubwt to workman's compensation laws of California."Contractor's hiring or sub-conuitcting signature <br /> rertities the fallowing:"I certify that in the partormanca of the work for which th;s permit,s issued, I ThalI am ploy peraonit subject to workman's compenia- <br /> tion Iowa of California." <br /> The appilcant st gall for ail r uir�specuons. Complete drawing on reverse side- <br /> Signed mow.. [�,4 ILA -0 Jitla: Da to: <br /> F R D RATiNENT USE ONLY <br /> A s t / 7 Area _ <br /> ppl•wr�Accepted by Date _ <br /> Pit or G t Inspection byater Final Impact on by ate <br /> Additional Comments: <br /> i <br /> Apylicant - Return all copitt;, 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 /> INFO <br /> [RFEE AMOUNT DUE AMOUNT REMITTED CASH prCEIVED By DATE PERhtiT'NO, <br /> . E"17-24 EV.i sf f '' VI r 8-1-7 <br /> EH <br /> 1 <br />