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APPLICATION FOR PERMIT � S' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONc <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 h <br /> PEMIT EMIRES 1 YEAR SROM 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 coadpliance with San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 11, Lot Size/Acreage <br /> Job Address ��4 " 2D " S City _<_77e-AJ <br /> Owner's Name O o Address � Phone <br /> 9 � ��4�'�'��'� s�7«✓ 77' 3 <br /> �� Li+cense No. - Y7G Phone <br /> 47/ <br /> Contractor FLr; 41�_.T��' Address vice Wel 0 <br /> TYPE OF WELL/PUMP: .i�� NEW WELL WELL REPLAC ENT C7 DESTRUCTION ❑ Out of Ser 1 <br /> PUMP INSTALLATION 11 SYST REPAIR ❑ <br /> OTHER p Monitoring Well C.I <br /> I DISTANCE TO NEAREST: SEfiTIC TANK WER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG CUL RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS V.1 <br /> n Industrial 00!pan Bottom O Man ca Dia. of Well Excavation Dia. of Well Casing <br /> k U Domestic/Private ❑ Gravel Pack ❑ Cy ype of Casing Specifications• ^ <br /> ❑ Public f 1 Other Delta D th of Grout Seal Type of Grout. ,vim! <br /> G Irrigation ��Approx. Dept 0 Eastern Su a Seal Installed by l <br /> i Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Materia fi Depth . ■� <br /> Filler Material k pth - . {Jr" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIRIADDITION 0 DEST <br /> -AUCTION INC septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence ,.1Z Commercial— Other <br /> Number of living units:... Number of bedrooms r /t <br /> Character of soil to a depth of 3 feet: '`1Nater table depth <br /> SEPTIC TANK ❑ Type/Mfg f"' Capacity No."Compartments <br /> PKG. TREATMENT PLT.C1 Method ofDisposal <br /> r Distance to nearest: Well Foundation Property Line <br /> k , <br /> F LEACHING LINE- Total kNo. $-Length of.lines._ -- -- Total lerigth7isixa - <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line ^ <br /> SEEPAGE PITS 11 Depth Sian Number <br /> SUMPS # Ll (`Distance to nearestcWell Foundation Property Line <br /> DISPOSAL PONDS © u l <br /> I hereby certify-that I`have prepared"")his-application and thal"th6wd—rk will"be done in accordance with Sen 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 compensation laws of California," Contractor's hiring or subcontracting signature <br /> certifies the following; "1 certify that in.the,performance of the.Work for which this permit,is issued, i_shaN_employ_personLs subject to workman's compnsa <br /> tion taws of California." <br /> The applicant must call for all required inspections. Complete d►awing on reverse side. t <br /> Signed x Title: Date: �y�E/ <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Data y Area <br /> Pit or Grout Inspection by I� Date .. Final Inspection by Sew Date . <br /> Additions[Comments, I� <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROAMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, p O BOX 2009, STOCKTON. CA 95201 <br /> FEE A AUNT DUE OUNT REMITTED CASH RECEIVED BCK# Y DATE PERMI1 NO. <br /> )NFO <br /> EH13.24IREV.1/4141 <br /> EH {.0 <br />