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- "-PLI CATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 1-e7' 07=- <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ' pp /Oz 7-0 rtg7z-- <br /> PERMIT EXPIRES 1 YEAR FROM_DATE IS9REDD <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 /> � <br /> Job Address 1/ Al, 2�1Z/,,- 9 City 4_tgj)L _ Lot Size/Acreage O—g�AG <br /> Owner's Name. TDA il9ii.—T Address 56,�r'!E ^^ Phone <br /> Contractor ,kJc20,Rj.- Address License No. Phone <br /> TYPE OF WELL/PUMP- NEW WELI,:'-❑ - WELL REPLACEMENT.0- - —DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATI N ❑- -SYS M REPAIR ❑ OTHEA-'Cf -Monitoring Well C7 <br /> DISTANCE TO NEAREST:-SEPTIC TANKSEWER LINE DISPOSAL FLD. PROP, LINE <br /> FOUNQATION:�-' AGRICU -.-RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLXAIEA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Ma c Dia. of Well Excavation Dia. of Well Casing <br /> (7 Domestic/Private ❑ Grave Pack' 0 racy Type of Casing Specifications <br /> I"I Publii — . Other T Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Dept I I Eastern Surface Seal installed by <br /> Repair Work Done L3 Type of Pump H.P. - State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Ma Tial & Depih <br /> ` Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence°/Commercial— Other ���W/W/6. <br /> Number of living units; __/_ Number of bedrooms_ = Y <br /> Character of soil to a deptIT of 3-faetsA'�b C e-A;j �` Water table depth <br /> SEPTIC TANK. 5- Type/Mfq Capacity No. Compartments y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well SO Foundation._SO r Property Line <br /> LEACHING LINE No. & Length of lines „ Total length/size B4 <br /> FILTER BED ❑ Distance to nearest: Welt /&'O-eL- Foundation Property Line <br /> } SEEPAGE PITS I . Depth �� Size 4-2. " — Number <br /> SUMPS Lt Distance to nearest: Well L", ` Foundation ` d ' 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 San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: 1 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." <br /> The applicant must call for all required-inspections. Gomplete-drawing-on-reverse-side. <br /> Signed X Title: Date: 7^ Z 3 T c, <br /> F(CEPARTMENT USE ONLY <br /> icetion Accepted by4Date O Area <br /> Pt Grout Inspection by Y� Q - 1_� )ate� Q Final Inspection by Date-e- -�O <br /> t j <br /> ..Additional Comments: <br /> Applicaat --fleturn'a`ll copies torssSa.n Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0009, Stockton, CA 95201 <br /> r� FEE AMOUNT DUE AMOUNT REMITTED C R RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 13.21(REV.I)K5! <br /> } EH.I-2e "t <br />