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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT-EXPIRES 1 YEAR -FROM DTE ISSUIMk <br /> (Complete in Triplicate) b <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. I /j{}f ' . <br /> Job Address City <br /> L�, 5 k,[._S T�� ^ Lot Size/Acreage <br /> t r t t� Address Y Phone <br /> Owner's Name p C f f <br /> Contractor <br /> t dress's�J•7i� Wcense No. WL _Phone `31r' 2-44 <br /> Service Well 0 <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMEN 1.1 DESTRUCTION ❑ �'t of <br /> Well ❑ j <br /> PUMP INSTALLATiO SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC}'ANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM ARI A CONSTRUCTION SPECIFICATIONS <br /> L-1Industrial0 Open bottom ❑ Manfeca Dia. of Well Excavation <br /> r Dia. of Well Casing <br /> Type of Casin t Specifications <br /> mastic/Private ❑ Gravel Pa6k L7"Tr c�r J 9- <br /> `1'1 Public 11 Other zI T Dattel Depth of Grout Seal �� Type of Grout �rr <br /> I 1 Irrigation Approx. Depth I Eastern Surface Soul Installed by Y <br /> Repair Work Done U Type of Pump H.P�� -_ State Work Done„_ .J <br /> Sealing Material i Depth <br /> Well Destruction ” 0 Well Diameter r <br /> s Tiller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION i I DESTRUCTION I I (No sepk system permitted if public sewer is <br /> ,.F <br /> available wi'tMn 200 feet.),:. <br /> Installation will serve: Residence— Commercial_ Other '!, <br /> Number of living units: Number of bedrooms <br /> Character Of soil to a depth of 3 feet: Water table depth i <br /> a <br /> SEPTIC TANK. O Typo/Mfg Capacity �. No. Compartments 1 <br /> PKG. TREATMENT PLT.❑ w `r? Met hdd.of Disposal . <br /> Distance to nearest: Well Foundation, ;/ ,Property Line <br /> 's' - # <br /> LEACHING LINE C1 No. f1 Length of lines Total length/size <br /> FILTER BED 1:1ea <br /> Distance to nrest: Well Foundation_., -- --- <br /> bf <br /> -Property-Line. <br /> SEEPAGE PITS 11 Depth Size ' Num or <br /> SUMPS Ll Distance to nearest: Well Foundation ----- --- Propeny..L.in'e-- ` 3 3` <br /> DISPOSAL PONOS ❑ �� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 r ii is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws o1 California."Contractor's hiring osb 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 compansa- <br /> tion laws of California." s '4 <br /> The applics t st call f uired impactions. Complete drawing on r rse side. y de2 <br /> SigJlfp Title Date: a <br /> E FOR DEPARTMENT USE ONLY 4 ^ <br /> Application Accepted by lwmm Date_�?`OArea 7 <br /> ILI> <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> l <br /> t Additional Comm,nts: <br /> !I Applicant - Return all copies to: San Joaquin County Public Health Services 'Ile <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED 1 CK 4 CASH RECEIVED BY DATE PERMIT,NO. <br /> INFO 9 <br /> . EM 1}21 111EV. �+�SI <br /> Pip, -45.00 r�4 <br /> { EH 1420 -c?2 g <br />