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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION + <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 i <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YM FROM DATE ISSEWU <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 mad"e.`in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaqula County Public Health Services. <br /> r'. <br /> Job Address <br /> City Lot Size/Acreage <br /> t <br /> Owner's Name �/ ' ,Address `Q Phone <br /> Contracts Address 2- i a T �License.No_-2_ ?_d�Phone <br /> TYPE OF WELL/PUMP':.t- NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION u Out of Service Well <br /> j f;PUMP INSTALLATION O SYSTEM REPAIR ❑ �` ;r,OTHER ❑ Monitoring Well C3 r <br /> DISTAN'bCTO,NEARES' ; SEPTIC TANK - SEWER LINES �' OISPOSAL'FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL + OTHER WELL PITS/SUMPS <br /> 3 UNTENDED USE r.4 -�rYPE OF WELL_j PROBLEMiAREA CONSTRUCTION`SPECIFICATIONS rJ <br /> C1 I0busty al _r ' O Opan Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia. of Well Casing <br /> i C] pomestic/Private Gravel Pack ElTracy Type of Casing_ Specifications <br /> I'1 Pubfic� _ 1.1 Other f 1 Delta: Depth of Grout Seal Type of Grout <br /> C I i li)gallon-- � Xpprox. Depth I l Eastern Surface Seal Installed by <br /> State Work Done' �J <br /> i�• A.P. � 4 ` <br /> Repair Work Done Cil ,Type of,Pump <br /> Wafl Destruction b. `Weil;mmeter., r <br /> Sealing.Material )'Depth ' <br /> "�._ Filler Material A Depth <br /> TYPE OF SEPTIC WORKS NEIN INSTALLATION REPAIRlADDITiON 1,I DESTRUCTION l I INo septic system permitted it public cower is <br /> available within 200 feet.) <br /> litffatii5n w111 serve Rssii9nce Coinrlerclal.i�. O[her ---�� �=- s^ <br /> 3. <br /> NuMbif of living unite: T Number of bedrooms <br /> Character of''s6il to @'depth of 3 feat: Water [able depth <br /> SEPTICTANK 's.`-p Type/Mfg Capacity No. Compartments <br /> f �, Method of Disposal <br /> PKG.T^ EA <br /> R3MENT PLT:❑ � <br /> +, 61stance to clearest: Well xj� Foundation_S5 3 .Property Line <br /> LEACHING11NE No. 3 Length of lines 'T Ttitat langth/size <br /> FILTER8ED 1 Cl Distance to neareii: Well t Foundation Property Line <br /> Nu <br /> ; SEEPAGE PITS 11 'Depth Si:e "�""" '-" mbe <br /> y - <br /> SUMPS '�Q 'bistance to nearest:, Well fe llor Foundation� Property Line <br /> DISPOSAL PONDS ❑ _ <br /> 1 hereby certify,Ihat I have prepared this 4P—Oicaii6n 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 iheafolfowing: "I certify that in'the performance of the work for which this permit is issued. I shall not <br /> employ any parson in such manner as to!become subject to workman's compensation laws of California."Contractor's hiring or$ub-contracting signature <br /> }' certifies the following: "I certify that in the performance of the work foe-which this permit is issued, I shall employ persons subject to workman's componss- <br /> tion laws of California." i <br /> I The applicant must callflo sUrrequired inspections. Complete drawing on reverse side. <br /> i Signed '"' ' '1 Title: Date: "1 � <br /> s DEPA ENT'U ONLYt <br /> ! Application Accepted by ' Date Area <br /> ° Pit or Grout Inspection by ' <br /> Date Final ,nap tion by pate <br /> Additional Comments: ��� ' <br /> Applicant -.Return all copies to:- San Joaquin County Public Health Services <br /> T Environmental Health Permit/Services <br /> . -�.. .....,_. :-,y... ..:';�. —445-N-•.8an-Joaquin, <br /> } ter- - FEE- AMGUNT Dt►E AMOUNT gEM1T7f0 � wNECE1VED BY DATE PERMIT'N0. <br /> INFO /I <br /> . EN 1}24 INEV.�i K !1 (/ <br /> EH 14•20 /` <br />