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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 /> PRUITEXP RES 1 YEAR FROM D ID <br /> (Complete in 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 City of Size/Acreage <br /> Owner's Name ..-dress Phone { <br /> �d,G �uyf <br /> Contractor ddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � OTHER 0 Monitoring Well C� <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 /> D Industrial ❑ Open Bottom 11 Manteca Dia. of WeIrExcavation Dia. of Well Casing <br /> C.l <br /> Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications <br /> C1 Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> ! I IrriS7ation __Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done . 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material•& Depth <br /> Depth Filler Material & Depth _ p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION W7 DESTRUCTION l I (No septic system permitted it public sewer is <br /> _ k available within 200 feet.) <br /> Installation will serve: Residence-!!f' Commercial _ Other <br /> Number of living units: ..,. Number of bedrooms_ L _ J <br /> Character of soil to a depth of 3 feet: 'Water table depth f <br /> SEPTIC TANK ®'r'Type/Mfg �' C-e'-I C Capacity t C, 0 4 filo. Compartments <br /> PKG. TREATMENT PLT..M t Method of Dispgsai e�t�+ e_r Q <br /> Distance to nearest: Well Ld 14 Foundation (0 0 Property Line a <br /> LEACHING LINE fJY No. & Length of lines J Tcytal length/size <br /> FILTER BED n Distance to nearest. Well *"Foundation �'Property.Line _Z--6 <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS LI Distance to nearest: ' Well Foundation Property Line a <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 �J <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 shelf 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 laws of California." <br /> The applic t MW call for all requir d ins tions. Co plat drawing on reverse side. <br /> Sign TiN Date: <br /> r. RDE RTME _USEONi.Y <br /> _. 7 <br /> Application Accepted by Date L�?moo Are �L <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services _ y <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUF AMOUNT REMITTED CASH CK Ill RECEIVED BY DATE PERMI7'NO. <br /> f' ��r/// <br /> + EH13.241REV.I/M51 �U• _ VV � �`�9 - 11h I-N.,X91 <br /> EH t4-A ` 1 <br />