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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)46$-3420 <br /> P O BOR 2009, STOC,KTON, CA 95201 <br /> r DTgMIT Ek-IRES 1 YEAR FROM DATE $-VED <br /> f Ir <br /> (Complete in Triplicate)" , <br /> i <br /> ... <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 /> s Joaquin County Public Health Services. r +� <br /> EL) <br /> Address <br /> ,� . /✓I�� L� City tl�/ Lot Size/Acreage <br /> II . <br /> Owner's Name Address 174141- Q:Z) Phone <br /> r - <br /> Contractor Address License No �F'hane <br /> TYPE OF WELL/PUMP: �I, NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ out of Service Well 0 <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER p C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 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 /> f.a <br /> Domestic/Private Cl Gravel Pack ❑ Tracy -Type of Casing Specifications <br /> 1'1 Public 1-1 Other rl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation 3� .Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material 3 Depth `rfi <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l I (No septic system,,permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms__�3- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> tt SEPTIC TANK. d jVpe/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ �� Method of Disposal <br /> [,Distance to nearest: Well foundation Property Line <br /> LEACHING LINE W --No. fZ Length of lines _ Total length/size <br /> r. �,�-�.,�c� <br /> —7— <br /> FILTER BED ❑ ,i Distance to nearest: Well SZ2F— Foundation -r_1�_Property Line r� y <br /> .I <br /> SEEPAGE PITS1 I 'Depth Size r 'Number. <br /> i' SUMPS LI NDistance to nearest: well Foundation Property.One <br /> _DISPOSAL PONDS. ... ..p..,,l !7== <br /> 1 hereby certify that I have prepared this applicawmand that the work will be done-in accOrdance-with San Joaquin county ordinances, state laws, and <br /> r�_�--- x <br /> rules and regulations of the San Joaquin County �. <br /> Home owner or licensed agent's signature certifies the)ol[owing:,''I certify that in the performance of the work for which this permit i$issued, I shall not <br /> employ any person in such manner as to.become.subject to workman's compensation laws of.Californias Contractor's hiring or sub-contracting signature <br /> "I <br /> certifies the following: certify-that-in-the performance of the work for�which this permit is,issued, I shall employ,personsisubject to workman's compensa- <br /> tion Yaws of California.'I 4 i l <br /> The applicant must call;tpr jAqui ed1in�pections. Completedrawing`ott teve�se sii9a:' �'� <br /> { Signed X i' Title: . ;_ �s%b -- _-- Date: lG <br /> 1, ORD ENT USE ONLY <br /> Application Accepted by; .Date res <br /> Pit or Grout Inspection by 'Date Final Inspection <br /> I ¢ <br /> Additional Comments: <br /> t Applicant ^ Return all copies to: San Joaquin County Public Health <br /> t ;I Services, Environmental Health Permit/Services <br /> ! 1601 E. Hazelton Ave., P 0_Box 2009, Stockton, CA W95201 -^a <br /> _F.EE_ -.. AMOVNT-DUE —'AMWUNT-REWIITTED " ASH RECEIVED-SY <br /> INFO ii� <br /> . EH 13-21 IftEV. i M SY S(L •i \-"C�13 4 Ck h <br /> EH 14-26 [ l <br /> t r - <br />