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w r. <br /> APPLICATION FOR PERMIT <br /> a• � ra <br /> �E 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 is Triplicate) <br /> Application is hereby made'to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> f application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> p Joaquin County Public Health Services. <br /> Jab Address a ` �7 r ��'e �� 2�i' City E55%c`+k*YN Lot Size/Acreage <br /> jo CSf <br /> Owner's Name 1pAddress , �'�° Phone <br /> Contractor� "� Address S. Kv-f?�n _ License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br />{ PUMP INSTALLATION ❑ SYSTEM REPA1 OTHER ❑ " Monitoring Well C3 <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA'L:-FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> [. <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public f:7 Other ' , I-1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation -.Approx.-Depth I I Eastern Surface SealAnstalled by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction © Well Diameter Sealing Material & Depth <br /> ' Depth C Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I _,DESTRUCTION I I (No septic system permitted if public sewer is \ <br /> available within 200 feet.) <br /> installation will serve: Residence Commercial____": Other-t <br /> Number of living units: _L_ Number of bedrooms <br /> 'Il <br /> n y. <br /> Character of sail to a depth of 3 feet:t '^4 ��` Water table depth M <br /> SEPTIC TANK K •Type/Mf --i ���� '� : _ Capacity » No. Compartments, <br /> PKG. TREATMENT PLT. ❑ ter '-7r , ��r Method of Disp os �k• 4 <br /> Distance to nearest: Well �'' Foundation <br /> Property Line �► <br /> LEACHING LINE $9 No. & Length of lines 4 .; Total length/size <br /> I <br /> FILTER BED C-) Distance to nearest: Well !00:k Foundation 9e4' Property Line '�►� <br /> *' SEEPAGE PITS- _ K.�DepthSize 52 1 'LT Number <br /> SUMPS Ll Distance to nearest: Well -0 Foundation Property Line - - <br /> DISPOSAL PONDS ❑ <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 <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 taws of California." <br /> j The applicant m t call for all required insPections. Complete drawing on reverse side. <br /> f41E it t, p <br /> Signed Title: '_ __ ____ _ Date: <br /> i F DEPARTMENT USEONLY <br /> h4-- <br /> I Application Accepted to Date , Area <br /> P1 Final Ins <br /> ice, r Grout inspection by Date Inspection b tate <br /> Additional Comments: <br /> Applicant - Return all copies to; San Joaquin County Public Health <br /> I0 Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 r <br /> IFEE <br /> NFO AMOU DUES; AMOU EMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EN17-26IRE <br /> V.1/#t5) !V & <br /> EH 442E 1 VV FV/ 0 <br />