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Oak �Ceg,. a, P �� APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> DTiRYTT FXPIRSS 1 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby taade to San Joaquin County for a permit to construct and/or install the work he <br /> xein described. This <br /> i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> k Joaquin County Public Health Services. <br /> �. (2, kI e_ City Lot Size/Acreage <br /> Job Address <br /> '— /� Ir'1 E Phone 33 112- <br /> Owner's Name1 /410-409-0- — Address <br /> Contrattor �� -tM^ __Address <br /> S _ /�[ r @ License No. ,,�7�ZZlc8-Phone 6S-$1l2 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Out ofServiceMonitoring <br /> Well <br /> Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR IR ❑ OTHER O r <br /> '-DISTANCE TO NEAREST;_$EPTIC TANK SEWER LINES y'S'& -. DISPOSAL FLD. PROP. LINE <br /> ' FOUNDATION ! AGRICULTURE WELL — OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // <br /> 0Industrial ❑ Open Bottom ❑ Mameca Die, of Wall Excavation <br /> Dia, of Well Casing <br /> !� �- <br /> U Domestic lPrivate ❑ Gravel Pack ❑ Type of CasinTracy 9 SSpecilications <br /> ID Public C.1 Other 0 Delta Depth of Grout Seal w I Type of Grout <br /> Clzwe <br /> Irrioation ^Approx. Depth 0 Eastern 5uda'ce Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. Stara Work Do _ <br /> Weil Destruction X Well Die er a e <br /> Depth 0 r Filler Material & Depth <br /> ji��TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION CI DESTRUCTION G (Nails l tiw thin m f mi led if public sewer is 00 <br /> stC7" <br /> Installation will serve: Residence— Commercial_. Other <br /> I Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> +� SEPTIC TANK. _ ❑ Type/Mfg Capacity__ No. Compartments <br /> tQ PKG. TREATMENT PLT, 0 Method of Disposal 4 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Ct Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS . ❑ <br /> 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 Son Joaquin County <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 /> I employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature " <br /> L certifies 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 is." <br /> he <br /> The ep " ant must mall for r ire to Pe, lions, Complete drawing on reverse side. <br /> Signed Title: 6yL` Date: f <br /> OR DEPARTMENT USE ONLY IV <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by DateJq3 <br /> ' / <br /> Additional Comments: t � <br /> Applicant - Return all copies to: SAN JOAQUIN OUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOVNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. <br /> INFO JII 9- 1 <br /> ^^ Q (� <br /> . EEN 14.211 —a W-40M 13.24 IREV,i i lit) L Y� o� l [ <br />