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i APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />` ENVIRONMTAL HEALTH DIVISION <br /> f 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 9520-t <br /> t <br /> PERK T E%PIRES 1 Y FR M D TE <br /> (Complete in Triplicate) S <br /> Application in hereby made to Sao Joaquin County for a permit to construct and/or install the vork herein described. This } <br /> ayplication ie made in ceatpliance with Ban <br /> Joaquin County Public Health Betwicea. Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San 1 <br /> Job Address � <br /> City 71WLot Si ze/Acreage <br /> Owner's Name � Lil_..a <br /> Address S <br /> a Phone I <br /> Contractor ' <br /> Address <br /> TYPE OF WELLlPUMP: NEW WELL © License No. �Phone -2 <br /> WELL REPLACEMENT n DESTRUCTION ❑ Out of S <br /> PUMP INSTALLATION p- ervice well C1 <br /> r-.'�, <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM AFFAIR [] _.. -- OTHER ❑ Monilorr ni Well <br /> -- SEWER LINES D <br /> FOUNDADISPOSAL FLO.TION AGRICULTURE WELL PROP. LINE <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom -�p Mane <br /> rl Domestic/Private Dia. of Well Excavation <br /> 0 Gravel Pack L7 Trac Dia. of Well Casing <br /> I'I Public Y Type,of Casing <br /> I:7 Other Cl Delta +�.�__,,,;_„- Specifications <br /> I I Irrigation Uepth of.Grout Seal.��_ __- Type of Grout � <br /> Approx. Depth I f Eastern Surface Seal Installed by ` <br /> Repair Work Done' L7 Type of pump _ H.P. <br /> Wall Destruction 0 Well Deter Sealing Materiae Depth State Work Done w <br /> 'Depth filler lfaterisI Depth + <br /> TYPE OF SEPTIC WORK: NEW aNSTALLAIIII I I REPAIR/ADDITI%JrY (f DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation wilt serve: Residence Other available within 200 feet.) <br /> Commercial` <br /> Number of living units: _,--L Number of bedrooms <br /> Character of$oil to a depth of 3 feet: ,.i <br /> SEPTIC TANK. 1. O Type/Mfg E Water table depth <br /> PKG. TREATMENT PLT. 0 - Capacity-. Na, Compartments { <br /> Distance to nearest: Method of Disposal� <br /> Well Foundation y ` <br /> --Property Line'--,, <br /> LEACHING LINE No. lei Length of lines <br /> FILTER BED r Total length%sire / <br /> D Distance to nearest:. Well A ` Foundation <br /> --�`� Property Una,.1@d <br /> SEEPAGE PITS I Depth1 Size rr ' <br /> SUMPS Numbiir <br /> L i Distance to nares Well <br /> DISPOSAL PONDS p - — Foundation_g�! ` Property Lina <br /> I hereby certify that s have prepared this application and that the work will be done in accordanwith S <br /> ce an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 11s e <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 compensaiion laws of California." Contractor's hiring or sub-contracting signature <br /> ceRifies 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�--x <br /> tion laws of California." _ <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X-4� <br /> Title: <br /> Date. 11-/6 -9 Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r !� �� Area f <br /> .-" Date �f <br /> Pit or Grout Inspection by f Data <br /> -�—�� Final Inspection by DataA&� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Service$ <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 { <br /> FEE AMOUNT DUE AMOUNT REMITTEDHCASH;,ERECEIVED <br /> INFO BY DATE PERMIT'NO. <br /> IH 1121{AeV.rrnsrrDID � <br /> iN to-20 <br /> �z 9� 3 71,5 <br />