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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 />PBRHIT PSXPIRES I 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. 5h9 and 1862 and the Rules and Regulations of San <br />Joaquin County Publ <br />i <br />c <br />Health Services. <br />Job Adm —t �UCJ.J L//!v r� 02kK �,l Citv S%^& _ Lot Size/Acreage <br />Gr <br />Ep(e, SC. Phone <br />Owner's Name <br />_ Address 4 —?&- <br />�j <br />Contractor eJ 11 �IG _<. Address f ." 0. .. 'q.3 �°D z~t1Ttt,flo� LicenseNo. Asilt2iz— Phone <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ 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 />1S/ <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE <br />TYPE OF WELL • ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />177 Industrial <br />❑ Open Bottom 'D Manteca Pia. of Well Excavation V Dia. of Well Casing <br />❑ Domestic/Private <br />❑ Gravel Pack Ll Tracy Type of Casing Specifications - <br />I'I Public {_ <br />Ia Other fl Delta Depth of Grout Seal - Tvpe of Grout <br />I I Irrigation <br />_. Approx. Depth I 1 Eastern Surface Seal Installed by <br />Repair Work Done U <br />Type of Pump , H.P. State Work.Done _ <br />Well Destruction 0 <br />Well Diameter Sealing Material 6 Dtpth ' <br />Depth Filler Material L Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 11--lNo septic system permitted if public sewer is <br />available within 200 feat.) <br />Installation will serve: <br />Residence Commercial _ Other <br />Number of living units: <br />Number of bedrooms —3— <br />Character of &oil to a depth of 3 feet: Watar table depth <br />SEPTIC TANK <br />O Type/Mfg Capacity No. Compartmants <br />PKG. TREATMENT PLT. <br />0 Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />1'i' No. ,& Length of lines �� r Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well � Foundation _ v ' Pror-Qny Line ,!a <br />SEEPAGE PITS <br />I& Number <br />-k Depth -2 -Tf Size_ <br />SUMPS <br />CI Distance to nearest: Well -&P-Jt—Foundation xS ' Property Line <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, lishall employ persons subject to workman's compensa- <br />tion laws of Californla." <br />The applicant must call for all required lnspections. Complete drawing on reverse side, <br />Signed X- -4 Title: Date: <br />R DEPARTMENT USE ONLY <br />Application Accepted byDate=? �r PAree�__e____ <br />n �l-- Date 5 �� <br />)Grout Inspection by, ri/1 _ c Datr -�� _JO Final Inspection by <br />Additional Comments: <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 />a EH 1371iREV.Iin5) <br />EH IA -25 <br />INFO <br />AMOUN DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY <br />DATE <br />PEAM17'N0. <br />7o'bo <br />-7©,0C) <br />1S/ <br />/-.0 <br />