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APPLICATION FOR PERMIT " 7�P <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-9420 <br /> P O BOK 2009, STOCKTON, CA 95201 /QJ, <br /> PERMIT EXPIRES T YEAR FROM DATE i ffl <br /> (Complete in Triplicate) <br /> Application 1e hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> Application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 <br /> Joaquin County Public Health Services. l?/ and the Rules and Regulations of ban <br /> Jub Address -27 ,�E.��Lb ,e �,�)'�] <br /> City WL Site/Acreage <br /> Owner's Name Address / <br /> Phone <br /> Contractor dress icense No.01 e 00411,14 Phone 7� /a- <br /> TYPE OF WELL/PUMP: NE WELL^ WELL REPLACEMENT II DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLAT N SYSTEM REPAIR Ll OTHER ❑ Mopitorin� Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,--� DISPOSAL FLO."-' PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL !! PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> 11 <br /> I Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of WOR Cas <br /> Domestic/Private -ArGravel Pack ❑ Tracy Type of Caning Specifications <br /> I I Public gthAer FI Delta Depth of Grout Seal Ty of Grout <br /> Int adore ,�j Approx. Depth I Eastern �t/elate Soul Installed by <br /> Repair Work Done ❑ Type of Pump fid{-. H.P. /A: State Work Don_ <br /> Well Destruction U Well Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INc septic sysiom permitted it public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: _ Number of bedrooms <br /> Character of act to a depth of 3 feel: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> �' <br /> Method Of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. 8 Length of lines Total length/size <br /> FILTER BED CI Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property lkte <br /> DISPOSAL PONDS El <br /> 1 hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin Coynly 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sulfconiNcting 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 o <br /> lion laws of Californla.- fired r� mpanu- <br /> The applicant my _ s omplele drawing on raver,jali <br /> Signed X- L/ G 8' <br /> Date: <br /> F DEPARTMENT USE ON <br /> <�Aation pceptod by Date �� 15 . <br /> Area <br /> out specticn by Data Final Inspection by��� �-L ZS cj <br /> Dna <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Ravironmental Health Perm t/Services <br /> 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> • EHI]], REV , .�, 13y�ro A 6-3- ,o . atA89 ,. <br /> EH 11]a <br />