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P�1S � oC) <br />�1l <br />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 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />r) s�'# z�-F;Y (=F; )i't.•' r c� sie 000� �' fk+ y. 'j <br />JVU MUVloaa <br />- "••- — <br />�M �" /'L/ IV / v J Phone <br />Owner's Name <br />1 1,1, Address <br />Contractor <br />Address License No. Phone _ <br />TYPE OF WELL/ PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />CI Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />f.l Domestic/ Private <br />❑ Gravel Pack O Tracy Type of Casing Specifications <br />1'I Public <br />(-I Other n Delta Depth of Grout Seal Type of Grout <br />I I Irrigation <br />_ Approx. Depth 1 I Eastern Surface Seal Installed by <br />Repair Work Done 0 <br />Type of Pump H. P. State Work Done _ <br />Well Destruction ❑ <br />Well Diameter Sealing Material Z Depth <br />Depth Filler Material i Depth <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence - Commercial Other <br />Number of living units: <br />Number of bedrooms +� <br />Character of soil to a depth of 3 feet: Water table depth ) <br />SEPTIC TANK <br />❑ Type/Mfg s- Capacity, No. Compartments <br />PKG, TREATMENT PLT. <br />❑ r r� Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />� <br />❑ No. & Length of lines _���✓ Total length/size i CY <br />FILTER BED <br />❑ Distance to nearest: WeII r Foundation -- /+ Property Line f <br />SEEPAGE PITS <br />11 Depth �� ' Sizers Number s� <br />SUMPS <br />��`- / �i t" Property Line <br />LI Distance to nearest: Well 4- Foundation ' <br />DISPOSAL PONDS <br />❑ <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 laws of California." <br />The applicant mu t all for all required inspections. Complete drawing on ,reverse side. ? �b <br />Signed X�O ',�, m ���!L _ Title: lir Date: <br />aFEPARTMENT USE ONLY q <br />Application Accepted by d,,nt Y� Aft -06— Date 3' — Le Area <br />Pit or Grout Inspection by Date Final Inspection by r�Date <br />Additional Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health <br />Services, Environmental Health Permit/Services <br />1601 E. Hat:elton Ave., P 0 Box 2009, Stockton, CA 95201 <br />EM 13-24 (REV. r r n 5. <br />EH A-25 <br />46M <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH CK <br />RECEIVED BY <br />DATE PERMIT NO. <br />0 LLr <br />Ag),F,, ' <br />3 3 -5c 6 - &7 <br />