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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete its 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 iclCi Lot Size/Acreage <br /> AZQE <br /> Owner's Name ddress � I <br /> Phone <br /> //-�ZPho <br /> " ne g l e E <br /> Contractor .�Address License Nos <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEfVIEN7 C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U �. <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,,, - -F <br /> ❑ Industrial LI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WeII Casing:r <br /> f:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I ! Irrigation __.Approx, Depth I'I Eastern Surface Seal Installed by <br /> Repair Work Done U 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 INSTALLATION I I REPAIRIADDITION I I 0 STRUCTION I I (No septic system permitted if public sewer is <br /> ava ble within 200 feet.) <br /> Installation will serve: Residence Commercial_Other _Wl " <br /> Number of living units: Number of bed Of <br /> Character of soil to a depth-of 3 feet: Water table depth <br /> SEPTIC TANK. ( r Type/Mfg, ° l -� Capacity - No. Compartments , <br /> t <br /> PKG. TREATMENT PLT. 0Method of Disposal <br /> Distance to nearest: well LW 4 Foundation Property Line <br /> LEACHING LINE Jeal No. & Length of lines Total length/size al 7 <br /> FILTER BED O Distance to nearest: Well Foundation JQJ :JE Propegy Line._ <br /> a i <br /> - •t <br /> SEEPAGE PITS Depth SizeuW Number <br /> SUMPS LI Distance to nearest: Well &V 4 Foundation iOrl Property Line ' <br /> DISPOSAL PONDS 0 <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, anrd . <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 taws 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 call for all required insPections. Complete drawing on reverse side. <br /> Signed Title: r Date: s �� ' <br /> FOR PA TMENT USE ONLY <br /> Application Accepted byDate = Area <br /> �, <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> (1, 12-1 <br /> Additional Comments: f44 2-)i I 1 p"04L. <br /> Applicant - Return all copies 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 /> FEE AMOUNT DUE AMOUNT,REMITTED CK RECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> a EH 13.21 IRtV.1/H se <br /> EH 94-2e <br /> f <br />