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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIR(MMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <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 /> a� <br /> Job Addresstr 9 R City Lot Size/Acre e <br /> Owner's NAddress T Phone <br /> I � ! J v Y 0 .l Phone <br /> Contractor T dress License-No. <br /> TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT EI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4 F . 4". OTHER ❑ <br /> Monitoring Well CZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM E <br /> CONST C ON SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ MantecDia. o e Excavation — ;Dia. of WeN Casing <br /> 1l Domestic/Private ❑ Gravel Pack ❑ TracyTy of Casing_ Specifications <br /> I'1 Public , n Other n Delta pth of Grout Seal Type of Grout <br /> — <br /> I _.Approx. Depth I I Eastern Surface Seal Installed by - <br /> I I lrridation a <br /> Repair V11oWDone 0 Type of Pump H.P. <br /> -� x`-State Work Done <br /> Sealing Material &'Depth 1 <br /> ' Well Destruction ❑ Well Diameter i t, , <br /> Depth filler Materiel i;Depth 1 y r <br /> TYPE OfISEPTIC.,WORK:_NEW INSTALLATION lir--REPAIR/ADDITION I I DESTRUCTION I I INo seplie system permitted it public sewer is <br /> _ available within 200 feet.) i r. <br /> j Installation will serve; Residence_..v Commercial } _ Other <br /> Number-of living units:' , Number of,bedroom_ <br /> Chaticter oil of stai depth of 3 feet: C Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> If <br /> PKG. TREATMENT PLT.❑ Method of Dispo <br /> Distance to nearest: Well F undafion Property Line <br /> I' Tor l I ngthlsize <br /> LEACHING LINE ❑ No. b Length of linos <br /> f FILTER BED ❑ Distance to nearest: Wall Foundation Property Line ^\�} <br /> SEEPAGE PITS 11 Depth Site Nu be, h ) �\\JJLLQ6 <br /> SUMPS Ll Distance to nee st: Well oundation Property line <br /> DISPOSAL PONDS ❑` <br /> I hereby certify that I have prepared &s application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Josquin•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 issusd, I shall not <br /> 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 /> 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 lawe of California." <br /> The applicant must all for all r iced in pections. Complete drawing on reverse side. <br /> ua �� <br /> SignedTitla: � � 1 �� Date: `9�_ -)� <br /> FOR DEPARTMENT USE ONLYd <br /> ? /� <br /> Date Area �/� /� <br /> Application Accepted by °' <br /> Pit or Grout Inspection by Date Final Inspection by Datil oLo2 <br /> Additional Comments: a4 Of RTi fi�CIAti2 jG /n , <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEOUNT REMITTED RECEIVED BY AM <br /> DUE AMOUNT .__DATE—.-- PERMIT.N <br /> .� <br /> INFO --CASH _ _.. <br /> .. � !�_ <br /> . EH 1 <br /> 3-74111EV.r/eb <br /> EH 14.28 <br />