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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCETON, CA 95201 <br /> PFJIMIT EXPIRES 1 YEAR FR9M DATE 1§5UED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. <br /> lJJob Address —li2nL�3 V riot to ���_ ''City � Lot Size/Acreage t� <br /> Owner's Name Address '�1J ,�..� I ', �'� Phone <br /> t,ontractoTf lra r �'� Addres /,/ rLicense No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E) DESTR TION ❑ Out of Service Well Cl <br /> PUMP fNSTALLATION El SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> R ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D1SP05AL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> [I Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private Ll Gravel Pack racy Type of Casing Specifications <br /> I'1 Public -1 Other I-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Appy . Depth l I Eastern Surface Sedl Installed by <br /> Repair Work Done 0 Ty Pump H.P. State Work Done <br /> Well Destruction ❑ ell Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br />* TYPE OF 5 TIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I ! DESTRUCTION (No septic system permitted if.public sewer is <br /> available within 200 feet.) <br /> p Installation will serve: Residence iL Commercial— Other <br /> J Number of living units: -L—' Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4 <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> w Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line Y f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line -- <br /> `` DISPOSAL PONDS ❑ -: M <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 San 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 /> employ any person in such manner as to become subject to workman's compansafion laws of California." Contractor's hiring or sub-contracting signature t <br /> certifies the following: "I certify that in the performance of the work for which thisermit is issued, 1 shall employ p p y persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed ` Title: <br /> -• Dara: Fd <br /> FOR DEPARTMENT USE ONLY h <br /> Application Accepted by . Oate Araa <br /> Pit or Grout Inspection by Date Final Inspection by Data 7 <br /> 7 q ,r, I <br /> Additional Comments: _ P� `�< �yl <br /> Applicant - Return all copies to: Sou Joaquin County Public Health _ <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> x f FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE P£RMl7 N0. <br /> r. INFO CASH <br /> . -:�' rt <br /> EH 13-24 tnEv.,iwz, ar —do <br /> .. <br /> EN 4,•2$ � <br />