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APPLICATION FOR PERMIT rV <br /> 1 . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <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 FROM DATESI SUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San'Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in eompliance.vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address N, city f377kd Lot Size/Acreage <br /> Owner's Name <br /> 111AA_.�2—' ._. Address :524"l e Phone ) <br /> i <br /> ContractorEGD yG>r E. I.� 1J Address A��GB�.�+� License No. �Y7d Phone ��3�F7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION 0 Out of Service Well ❑ j <br /> PUMP«ΡINSTALLATION_O— a SY7 REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICU LT _ WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE R CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Mantec - Dia. of'Well'Excavation'" Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications <br /> V1 Public CI Other alta Depth of Grout Seal Type of Groat c� <br /> I lfri(jation —..Approx. Deptk", <br /> I Eastern Surface Seal Installed by W <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ; Sealing Material & Depth <br /> Depth Filler Material & Dth <br /> TYPE OF SEPTIC WORK: NEW iNSTALLA ON I I REPAIR/ADDITION I I D TR CTION INo optic system permitted if public sewer is <br /> av 'able within 200 feet.) <br /> Installation will serve: Residence Wit"Commercial' ' Other <br /> Number of living units: Number of bedrooms y j <br /> Character of soil to a depth of 3 feet: ' ' Water table depth <br /> SEPTIC TANK . .❑ Type/Mfg } Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well , Foundation Property Line <br /> LEACHING LINE Cl No. & Length of linesTotal len th/size <br /> g 9 <br /> FILTER BED ❑ Distance to nearest: --Well Foundation_ Property Line f <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well J, 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 i <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 /> amploy 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> t <br /> The applicant must call for all required inspections. Complete drawing on r v�'�ferse side. <br /> e4 p 9 <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY —~� q <br /> Application Accepted by Date S i Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health f <br /> .Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO A^MOJUyN1T DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•N0. <br /> + EH 14.25 tV.I/is �.l9. I ..1• ', ITA 30 , 9 V\1 T Z3 1 I 94 I W 1 <br />