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d'FI ''fes --�.. •-_,- .. .�....� __ <br /> ;r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMMTAL HEALTH DIVISION <br /> I <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> - P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM D TE S <br /> (Complete in Triplicate) <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 ceupiiance,vith San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> 3 O�] / (J N STa City S r aU[ `� Lot Size/Acreage �� T <br /> XOwner's Name <br /> ` {� , i It- Address o� / 'V N 5-1-y!✓ VF Phone <br /> Contractor dy't"t�" i— Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well CZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL THER WELL PITS/SUMPS ._.� <br /> INTENDED USE" TYPE OF WELL PROBLEM A STRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom teca Dia. of We orlon Dia. of Well Casing <br /> E.) Domestic/Privala Gl Gravel Pack El Tracy Type of Casing Specifications <br /> 1"1 Public f:I Ot Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br />' Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth _ _Filler Material i Depth , <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> l il� Ilvailable within 200 feet.) <br />{ Installation will serve: Residence_ Commercial_ Other <br /> l Number of living units: Number of bedrooms <br /> Character of sol}to a depth of 3 feet: -Wttter table depth <br /> SEPTIC TANK. O Type/Mfg 1 Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ - Method of Disposal <br /> 4 Distance to nearest: Well Foundation Property Line <br /> { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth - Size Number <br /> SUMPS LI Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 s <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 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 /> r tion laws of Collfornla." <br /> The applic mustcall foreCrequired inspections. Complete drawing on reverse side. <br /> I >�16jgr*d X Title: O GAN �� Date: �7 <br /> PARTMENT USE ONLY [� <br /> Application Accepted by Date �y' I. _ Area © ICT' �J <br /> Pit or Grout Impaction by Date final inspection by <br /> ' +� _ Date 7 3 <br /> I Additional Comments: h <br /> Applicant - Return al copies to: San Joaquin County Public Health Services 7% )bf_ ss <br /> } Environmental Health Permit/Services <br /> # 445 K San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOU T REMITTEDRECEIVED BY ATE PERMIT'NO. <br /> 4.26 INFO 0 k7 y/ CASH 17 •/����/} <br /> • EM 13-24 IREY,t i n E� �� 1 �6 12? r F r / " <br /> EM 1 <br />