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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)4.68--3420 <br />P O BOX 2009, STOCKTON, CA 95201 <br />° EXPIRES 1 YEAR FRO11DATE rS�rr n <br />(Complete in Triplicate) <br />Application is hereby made to San Joaquin County for a permit .to construct and/or inatall the vork herein described. Th <br />application is made in camgiliarice vithwith San ,r <br />Joaquin Country Public Health Services, Oequin County Ordinance No. 549 and 1862 and the Rulea and Regulations of San <br />b <br />Job Address ,�r� . <br />- -- - _ City Lot Size/Acreage <br />Owner's Name <br />Address - <br />r-,� _ Phone <br />Contractor f'� r �^ � <br />TYPE OF WELL/PUMP: Address Pam �,f.'� <br />NEW WELL ❑ _License Ito. , Phone z_1 rl Af <br />WELL STEM EMENTREPAIR ❑ DESTRUCTION ❑ Out of Service Well C1 <br />PUMP fNSTALLATfON�tl <br />DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR [] OTHER ❑ Monitoring Well <br />'._`.""_"'----.•--...�-----�--�_ SEWER LINES -�. D15POSAL FLP. LJ <br />FOUNDATION R -AGRICULTURE WELL -�- PROP. LINE <br />INTENDED USE -^� OTHER WELL Z_� PfTS/SUMPS Ij <br />TYPE OFPROBLE <br />WELL MR <br />L7 Industrial <br />P Domestic/ Private <br />f'1 Public <br />I I Irrigation <br />Repair Work Done (� <br />Well Destruction ❑ <br />OF <br />_ A EA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom ❑Manteca Oia. of Well Excavation <br />Gravel Pack Q Tracy T <br />YPe of Casing-.. <br />L, Other <br />I -I pelta Depth of Grout Seal <br />Typrn Surface Seal Installed by <br />of Pump �. H P � <br />Weellll Diameter Seali —Stat° Work ­-Oone <br />-------.� <br />Sealing Material &Depth <br />Depth _- Piller Material & Depth <br />- I.wv rrvatALLATION I I REPAIR/ADDITION I 1 DESTRUCTI <br />Installation will serve: Residence _ Commercial — Other <br />Number of kving units <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />f I iNo septic system permitted if public sewer is <br />available within 200 feet.) <br />Number of bedrooms <br />Character of soil to a depth of 3 feet: _ <br />SEPTIC TANK. ❑ Type/Mfg --Water table depth, <br />PKG. TREATMENT PLT, ❑ '. - ' Capacity� No, Compartments <br />Distance to nearest: Method of Disposal <br />Well f Foundation <br />"__ Property Line <br />LEACHING LINT: 0 No. & Length of lines <br />FILTER BED n Distance to nearest: <br />Total longth/size <br />Well -h Foundation <br />..-� <br />Properly Line <br />SEEPAGE PITS I I Depth _ <br />5� .� Number <br />SUMPS !.I Distance to nearest: WeII- -- <br />DISPOSAL PONDS [A Foundation Property Line <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br />rules and regulations of the San Joaquin County ordinances, state laws, and <br />Home owner or licensed agent's signature certifies the following: "I ce <br />employ any parson in such rtify that in the performance or the work for which this permit is issued, I shall not <br />manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />certifies the f (alifoing 'Y certify that in the pa "'mance of the work for which this permit is issued, f shall em to <br />tion laws of roII i -wing! " p y persons subject to workman's compensa- <br />Tho apglica t 'Hirst call fo 'affil required ns "'m <br />The <br />drawing o reverse side• <br />Signed xiLMLZ c <br />-,� Title %Z <br />- ' " - W-------- �� Date <br />4•._��I�IORDEPARTMIEIIT U$E ONLY <br />Application Accepted by ---- �j, <br />- .-Jc - _1_ <br />Pit or Grout Inspection by Date Area�-)--:`--- <br />--- -- Date Final Inspection by �- _ Dat' <br />Additional Comments: <br />Applicant - Return all copies to: <br />FEE <br />INFO <br />3.24 (REV. I/ K5 <br />4.26 <br />San Joaquin County Public Health <br />Services, Environmental Health Permit/Services <br />1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br />AMOUNT DUE AMOUNT REMITTED <br />,UQ <br />RECEIVED BY f DATE <br />;IE�IIIVIW�o,J-��13 P <br />