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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Elan Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatlons of Ban <br /> Joaquin County Public Health Services. <br /> Job Address �D City/���1�� Lot Size/Acreage <br /> Owner's Name Address � 5� fla.� ' Phone <br /> Contractor ,�s L. i` UL[. � Address l'�� —)a icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial - O"Open Bottom O Manteca Dia.'of Well Excavation Dia. of Well Casing` <br /> [I Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other n Delta Depth,of Grout Seal Type of GroutSO <br /> I 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 O Well Diameter Sealing Material & Depth <br /> Depth Tiller Material.& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sower is <br /> �vaNalile within 1200;feet.) <br /> Installation will serve: Residence_e Comlm ircipl Other <br /> Number of living units: Numoet of bedrooms _ <br /> Character of soli to a depth of 3 feet: ��r�t1Dt✓ f+�C.f+zto / Water table depth <br /> SEPTIC TANK ❑ Type/Mfg __�- - l spacity'` 1<J ; No. Compartments <br /> PKG. TREATMENT PLT.❑ t Method of Disposal <br /> Distance to nearest: Well Foundation &r Property Line �s <br /> LEACHING LINE No. &'Length of lines _i�_ �T Total length/size <br /> FILTER BED ❑ Distance to nearest: VNeN TFoundation _ Property Line �'� r �� <br /> SEEPAGE PITS 1 I Depth Size Number <br /> SUMPS LI 'Distance to nearest: WON Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 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 E <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 compenss- <br /> tlon laws of California." <br /> The applicant mustcallfor required inspscWns. Complete drawing on reverse side. <br /> Signed X //'` gzw�!�� Title: T✓� Gr� Date: <br /> T USE ONLY <br /> Application Accepted by Dots <br /> �`� as <br /> 1 1.11 <br /> �.. <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> is <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> . E1 13-T4INEV.1/851 <br /> EM 14.26 <br />