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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I UAR FR N DATE IS§UED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or lnatall the work herein described. ie <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatiane of San <br /> Joaquin County Public Health <br /> Bervices <br /> 2 ` <br /> J City -5A&Lot Size/Acreage_ <br /> Job Address <br /> r � <br /> Phone _ <br /> Owner's Nsrna _ . _ _._--_ _ Address --_ ---.--�- <br /> 40A�F <br /> Contractor ddress <br /> S W License No.YIQ Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out Moa _ Well ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �_�_ S WER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION A RICULT WELL OTHER WELL PITS/SUMPS <br /> I� <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing t <br /> ' C7 Industrial ❑ Opeiag� <br /> Mant Dia. of Well Excavation -� <br /> Type of Casing_ Specifications. <br /> C.1 Domasticl Private 0 GracY Type of Grout-- <br /> VI <br /> rout <br /> rl OthDelta--- -Depth of Grout•Seal-- - , <br /> 1'1 Public , .u�V <br /> i I Irrigation A1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type ofH. State Work Done- <br /> Well Destruction ❑ Well D <br /> Ing Material i Depth <br /> DepthI aril er`Material ji Depth <br /> TYPE OF SEPTIC WORK: NEWI REPAIRlADDITION4 I ;DESTRUCTION I I INo septic system permitted if public sewer is <br /> > s s ----available within 200 feat.l <br /> installation will serve: Residence-1 Commercial + <br /> Number of living units: Number of bedrooms �. <br /> Charscts�of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ,t <br /> Mirttiod-of, <br /> PKG. TREATMENT PLT.Q <br /> Distance to nearest: Weli V IVFoundation 'Property Linet <br /> LEACHING LINE ❑ No. a Length-,of lines T a1 length/siz Y SS. <br /> FILTER BED ❑ Distance to nearest. Well y Foundation Properly Line' t ; <br /> SEEPAGE PITS 11 Depth Size N11mb4r } <br /> i r 11 <br /> SUMPS LI :Distance to rise t: Well .Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby ciirtify that i have prepared this application and that'thel work will be done in accordance with San Joaquin county ordinances, stats 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 do work for which this permit is issued, I shall not <br /> employ any person in such manner as to became 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, 1 shall employ persona subject to workman's compensa- <br /> tion Ism of California." k ' y <br /> The sppticant ust call to required in tions. Complete drawing on reverse side. <br /> I r Date: <br /> signed <br /> t Title: <br /> 3 _ ,i <br /> FOR DEPARTMENT USE ONLY ¢ q <br /> j Applkcat n Accepted by "'M L �~ t Date�' ..1,_ `S Area _ 11 <br /> � * � - <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 0 <br /> Addhional Comments: <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services $$k <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P ox 2009, Stkn, CA 95201 ti <br /> FEE AM04NT DUE AMOU REM1rrED R IVED BY D PERMWNO. <br /> i INFO <br /> . EN 13-24lffrv.r/Kitt <br /> EH 14.75 <br />