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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 0 BOX 2009, STOCKTON, CA 95201 <br /> �PERI[IT EXPIRES 1 YEAR FROM DATE IPSUED <br /> (Complete in Triplicate) A <br /> f <br /> Application 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 No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi s. <br /> Job Address 2 City Lot Size/Acreage <br /> Owner's NameAddressF' Phone <br /> , Contractor <br /> rid ress / L f f License Noyls- Phone S-9 <br /> t TYPE OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT C=1 DESTRUCTION I_1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLO. PROF. LINE <br /> FOUNDATION AGRIC LTURf Lat< OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL _PROBLEM ARE CONSTRUCTION SPECIFICATIONS y <br /> F [� industrial ❑ Open Bottom j ❑ Monte Dia. of Well Excavation —Dia, of Well Casing <br /> 1 4 —� <br /> �l Domestic/Private LI Gravel Pack CJ y Type of Casing Specificaiions * - <br /> 3 {"j Public (.1 Other Delta`. Depth of Grout Seal Type of Grout <br /> I <br /> I IriiUation ti r- _Approx. Der I I Eastern Surface Seal Installed by <br /> i . <br /> Repair Work Done 0 Type of Pump " H.P. State Work Done _ <br /> *` - - - r ` ` ( Seali Materiel & Depth <br /> Well pestruction ❑ F"_Well Diamet r ` <br /> Depth v 4 Ville Material i Depth _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 -- REPAIRIZDI ION�i�I` DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.] , ,1 <br /> : installation wilt serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of'3 feet: 4­_ 1. Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg `E Capacity,. fj 0.- No. Compartments <br /> 'y PKG. TREATMENT PLT. ❑ �- Method of Disposal <br /> Distance to nearest: Wellound <br /> fation PropertytL ne <br /> LEACHING LINE ❑ No. & Length of lines 72Tot I length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundationroperty Line <br /> r , <br /> f SEEPAGE PITS 11 Depth Size _ Number I <br /> SUMPS CI Distance to neark, Well o ndation ad -1 _ Property.Line <br /> r DISPOSAL PONDS D r <br /> a <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 /> f 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 r <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 i <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." rt r <br /> The applicant usLcall f require nspections. Complete drawing on reverse side. <br /> Signed X Title: Date: r <br /> r4�CFQR DEPARTMENT USE ONLY <br /> Application Accepted by ca, Date -`y Area <br /> `4 ` <br /> t <br /> Pit or Grout Inspection by Date Final Inspection by � ' Date � <br /> Additional Comments: <br />' r Applicant - Return all copies to: San Joaquin County Public Health <br />` t Services, Environmental Health Permit/Services <br /> j 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> �'► a EH 13-24 IREY. /n7Y1_ Z d - <br /> E1,174-211 YYY ff <br />