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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2. 009, STOCSTON, CA 95201 <br /> (20,9) 468--3447 <br /> PERMIT gXplRUS 1 'YEAR DATE IMIM <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 <br /> City Lot Size/Acreage <br /> Owr'a Name <br /> Address Phonilykh ) a* <br /> ne <br /> Conlraclor Address License No. Phone 4 <br /> TYPE OF WELL/PUMP: t NEW WELL D ELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well Cl F <br /> PUMP INSTALLATION O SYSTEM REP R Cl 071iER p Monitoring Well <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDA"ION AGRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WFLt PROBLEM AREA CONTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom © Mante/cAloC Excavation Dia. of Wafl Casing F <br /> U Domestic/Private Cl Gravel Pack O.Tracye of Casi SpecificationsM Public I:1 Other ❑ Deltath of Grout eal Type of Grout <br /> G I►rigalion �._.Approa, Depth ❑ Easterace Seal Instaled byRepair Work Done U Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter erial i DepthDepth rial i Depth <br /> YPE OF SEPTIC WORK:, NEW INSTALLATION REPAIR/ADDITION ML DESTRUCTION CI (No septic system permitied if public sewer is <br /> available within 200 lest.) r L1 <br /> Installation.will serve: .Residence>c Commercial _ Other <br /> Number of living unite Number of bedrooms <br /> Water table depth <br /> Character of sail to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type lMfg = Capacity - Z''No. Compartments Z- ` v? <br /> w � <br /> PKG. TREATMENT PLT. C) j r Method of Dtapo"sal <br /> f ' <br /> 10istance to nearest: Well, Foundation Property Line f 2�� I ►s <br /> EACHING-LINE No. & Length of lines Total lengthlaixe 1449 111 <br /> ILTER BED rn 10istance to nearest: Well Foundation.-- o -- Property Line <br /> SEEPAGE PITS ; I I Depth L Q—Sim Nu.Mber <br /> I Q..« � ` <br /> SUMPS { wUl r Distance to nearest: Well`c _. Foundation f Property. Line` • <br /> DISPOSAL PONDS U t <br /> j 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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify th#t-in the performance of the work for which this permit is issued, t 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 /> eamifies 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." i ; <br /> t The applicant ust call for al requirpd instions. Complete.drowing on reverse side. <br /> k <br /> Signed Title: Date: �. r�qtj) i <br /> F DEPARTMENT USE ONLY <br /> _.b-y.. � .. .,. Date � Area�1 <br /> Application Accepted <br /> —Pit or-Grout inspection'by -Date Fin61 Inspection by - Date <br /> Additional Comments: 11011 <br /> / r — <br /> Applicant - Return all copies t0,Y,SAN_JOAQUIN-,COUNTY PUBLIC HEALTH SERVICES <br /> x ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BO% 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> • EN iS•2�IREV. n S! r b� t C� 2D3 9 a2 <br /> EH A-26 .. <br />