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APPLICATION FOR PERMIT op � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH' SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 3 _YEAR FROM DATE ISSUED I <br /> (Complete in Triplicate) <br /> A lication is here meds to Sm Joaquin Count for + <br /> pp bi' y 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 / <br /> Health eels. I <br /> ��Job Address � S �7 - City Lot Size/Acreage <br /> Owner's Name _ W Address S 16 ���� _ Phone-I&Mlr' <br /> Contractor Address License hFa7i1LL�2/ Phone a'rJ/ <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> a FOUNDATION - -" "AGRICULTURE WELL-- -- --OTHER WELL - .PITS/SUMPS,__,_,, ^� <br /> INTENDED USE TYPE OF WELL wPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial r € •l Open,Bottom 01iiQ �a Dia. of Well Excavatihn Dia. of Well Casing <br /> C} Domestic/Private ❑ Gravel Pack L7'Tr y T pe of Ca _ <br /> !'I Public �` , 1-1 Other In Delta SAN�r ou 7 <br /> t I Irr" tion F' a App►ox, Depth" I I Eastern S Q I VISI <br /> Repair Work DaneU Type of Pump H.P, atq <br /> Wall Destructions ❑ Well Diameter. _ Sealing Nate <br /> I r Depth 4Piller Material i Depth <br /> TYPE OF SEPTIC WOR NEW INSTALLATION I 1 REPAIWADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) , v <br /> Installation will serve:,—"dence-.,— ommercial___- Other I <br /> Number of living units: -Number of badroo <br /> Character of wi to a depth of 3 feat: G ?# � _.. Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ? �` Capacity No. Compartments r <br /> PKG. TREATMENT PLT, ClV1 <br /> Method of Disposal t <br /> Distance to nearest: ,Well Foundation ° property Line } <br /> a <br /> LEACHING LINE Ll• .No. & Len&Wof lines f Total length/size 492 ► ? <br /> FILTER BED t ,'p 1 Distenci-lonearest: Well Foundation , Property,Cine 1 <br /> SEEPAGE PITS I I Depth <ev <br /> lumber <br /> SUMPS t IW—Distance to clearest: Well� Foundation Propertj Lino . r <br /> DISPOSAL PONDS I ❑ {` t <br /> I hereby certify that I hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cortifies 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." I <br /> The appliescaillfor all roqu' coons. Complete drawing on raMr <br /> e. 4 <br /> Signed7� Title: A)K Date: <br /> RTMENT USE ONLY <br /> Applieatlort Accepted b 9.eea—6_. a Dat s , -c"k Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 3 <br /> Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services+. <br /> 445 N San Joaquin, P O Box'•2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> • EN M24(REV.vflst <br /> EM 11.211 <br />