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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> PERMIT EXPIRES 1 YEAR FRPM D E ED <br /> (Complete in Triplicate) <br /> A lication 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 Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Cc <br /> unty Public Health Services. <br /> City � Lot Size/Acreage <br /> Job Address <br /> Owner's Name Address 7 y Phone l <br /> Contractor <br /> Address t 6 ��'! License No.,7l Yr�t,7 Phone 45 � ;V�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WLL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © Monitoring Well C] <br /> ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD P. LINE <br /> FOUNDATION AGRICULTURE WELL 0 ELL PITS/SUMPS <br /> INTENDE E TYPE OF WELL PROBLEM AREA CONS ON SPECIFICATIONS <br /> C-] Industrial 0 Open Bottom ❑ Manteca ia. of Well Excavation Dia, of Well Casing <br /> D Domestic/Private ❑ Pack racy Type of Casing Specifications. <br /> I'I Public CI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth rnn Surface Seal Installed by <br /> Repair Work Do Type of Pump H. - _ State Work Done <br /> Well De tion © Well Diameter Sealing eal & Depth <br /> Depth Filler Material & Dem pp <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO (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: Number of bedrooms 1+ <br /> Character,of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line <br /> SEEPAGE PITS 11 Depth Size Number �— <br /> SUMPS Ll Distance to nearest: Well Foundation 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: "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." Contractors 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 f,r all req 'red ins tions. Complete drawing on reverse side. <br /> [ Q <br /> Signed X Title: � Date: — <br /> RDEPARTMENT USE ONLY r <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Dale Final Inspection by Date <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEDUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO 1*73CASH �/J���Em 13-24IREV.iin$1 .D-( 5 �� ! / r�i ' /V 91 <br /> 11 <br /> ZV _ <br /> Eli 31-2a <br />