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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BO% 2009, STOCKTON, CA 95201 <br /> 7k EXP RES 1 YE R FROM DATE ISEUBD <br /> I' (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 /> �hi <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name LL <br /> ss <br /> 7� <br /> 11 - Address License No. ��Phone <br /> Contractor t of Service Well ❑ <br /> TYPE OF WELL/PUMP: ill NEW WELL ❑ WELL REPLACEMENT [] DESTR O T10N ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 <br />{ DISTANCE TO REST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE <br /> OUNDATION AGRICULTURE WELL _ WELL PITS/SUMPS <br /> -'INTENDED USE TYPE LL PROBLEM AREA C TION SPECIFICATIONS <br /> ❑ Industrial <br /> 0:Open Bottom wt <br /> Dia. of Well Excavation Dia, of Well Casing <br /> Specifications <br /> C7 Domestic/Private Cl,Gravel Pack ❑ Tracy Type of Casing . <br /> i <br /> !"1 Public Cl' n Delta of Grout Seal Type of Grout <br /> I I Irrigation �M .Approx. Depth I I Eastern Surface Seal b V ' <br /> Repair one U TyFpa of Pump H.P. State o <br /> Sealing Material Depth <br /> ell Destruction ❑ Weit Diameter <br /> iE <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_____ Other <br /> Number of living units: L Number of bedrooms <br /> w <br /> { Character of sail to a depth of 3 feet: Water table depth <br /> F SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I k Depth Size _ Number <br /> SUMPS Ll� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 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 laws of California." 11 <br /> The applicaqMust Ca or 911 r fired inspections. Complete drawing on reverse side. ] cy <br /> r Signed ,l Title: - - Date: ` <br /> FOR 612A TMENT USE ONLY <br /> Application Accepted by .I; Date Area <br /> I3 r <br /> Pit or Grout Inspection by Date Final Inspection by '^' Date 2 <br /> Additional Comments: <br /> Applicant -- Return alllcopies to: San Joaquin County Public Health <br /> .Ii Services, Environmental Health Permit/Services <br /> fIi 1601 E. Hatselton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> 27>Y <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. <br /> I INFO CASH ^l <br /> EH 13.241REY.t/nsi _w �LiCli-t �• 'Q f <br /> FH tt-2t! .I <br />