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APPLICATION FOR PERMIT � <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ��� <br /> P O BOX 2009,`STOCKTON, CA 95201 <br /> RIMIT RES YEAR D <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,n <br /> ;� q-ILI '!N' 6L(.le 1p,�fe City W Lot Size/Acreage <br /> Job Address [' (� ,� <br /> SrA(h l�I�NC L.. Address r1£- Phone <br /> Owner's Name � p <br /> Contractor <br /> I -f-Address S O i C9+J License No. Y-a I I Phone F'S <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT. ❑ DESTRUCTION ❑ Out of <br /> Well v <br /> PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/5UMP5" '�`" <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Ogen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ei T e of Casing Specifications <br /> [l Domestic/Private ❑ Gravel Pack El Tracy Yp <br /> I'I Public 11 Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —'IMApprox. Depth I I Eastern Surface Seal Installed by <br /> hState Work-Done -- --- <br /> Repair Work Done U Type of Pump - ---- <br /> __. <br /> Well Destruction ❑ Well!Diameter <br /> Well <br /> Material ti Depth <br /> Depth Filler Maters & Depth <br /> -TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is. <br /> ` I available within 200 feet.) - a <br /> installation will sena: Residence t! Commercial— Other '� <br /> i <br />�. Number of living-units: �� Number of bedrooms.�...._ # - <br /> Character of soil to a dept of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg L "Rv '"'� ' Capacity""f-2L5'0- �No7Compartrmnts� <br /> PKG. TREATMENT PLT. Cl IM t Method of Disposal C <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines U t { Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundation =Property Line <br /> i �M >�✓°M f t �'� CMe� i Ci T S <br /> SEEPAGE PITS I ) Depth Size Number <br /> SUMPS t Ll Distance to nearest: Well° y� Foundation— Property Line <br /> DISPOSAL PONDS <br /> ` I hereby cenify that I have prepared this application n`dythat 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'4a signature corrtif'ieslthe following: "I certify that in the performance pf 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 subcontracting signature <br /> certifies the following:"I certify that it the peiformsnce 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 must call for all Ir /�eq-uired in ctions. Complete drawing on reverse side, r r <br /> Signed ✓., Title: fid' Date: 1 <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by <br /> - Date�SL 4 `O Area <br /> III <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date <br /> I Additional Comments: I� <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services,-Lnvironmental`Healtl'i Permit/Services' <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> I IFEE NFO AM06NT DUE AMOUNT.REMITTED` CASH- RECEIVED BY DATE PERM17'NO. <br /> �( Y/�J fl . �f 7G <br /> . EM 13-24iREV.I/As) t ,� T Z J � V 0 <br /> EM 14.2E <br />