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1 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 /> 2 MIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> in Triplicate) <br /> (Complete p ) <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 an 1862 and the Rules and a tions of an <br /> Joaquin County Public Health Services. S Lo <br /> Job Address �U City` Lot Size/Acreage � <br /> Owners Name �t />� J`• `-'-Address i Y I ` Phone �v <br /> f <br /> f Contractor f Address Af S License No.f„a-.L_Phone <br /> TYPE Of WELL/PUMP: -- -¢­- NEW WELL.❑ _-.,WELL REPLACEMENT,❑ DESTRUCTION C) Out of Service-Well D <br /> PUMP INSTALLATION ❑ fSYSTEM REPAIR L7 OTHER ❑ Monitoring Well <br /> S DISTANCE TO NEAREST: SEP )C TANK SEWER INES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRfCUL E WELD• OTHER WELL. PITS/SUMPS ^_` <br /> INTENDED USE TYPE OF WELL OROBLrMAREY CONSTRUCTION SPECIFICATIONS 1 <br /> C7 Industrial ❑ Open Bot am /_Eai_ '�n <br /> +Ole. of Well Excavation'----, ',Dia. of Well Casing <br /> (..I Domestic/Private ❑ Gravel Pa k Type of Casing �"Specifications" - d <br /> E x <br /> f'1 Public 1:1 Other Depth 6f Grout Seal _Type of Grout <br /> I i Irrigation _.Approx. Depth SurfaceSeal Installed byRepair Work Done 0 Type of Pump State Work DoneWell Destruction ❑ Well Diameteri 'Material & Depth <br /> Depth er Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION rl REPAIR/ADDITION I I DESTRUCTION <br /> I I [No septic system <br /> ermitted if public sewer is <br /> P <br /> � <br /> r I available within 200 feet.) <br /> i <br /> t Installation will serve: Residence_,_..._ Commercial <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: A Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg `� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disp sal s <br /> k. <br /> Distance to nearest: Well Foundation Property Line <br /> s LEACHING LINE ❑ No. & Length of lines , T)ttal length/size I <br /> FILTER BED C7 Distance to nearest: ell Foundation Property Line I <br />� I <br /> SEEPAGE PITS 11 Depth1 Size _ N er { <br /> SUMPS LI Distance to neareg. well undation Property Line <br /> DISPOSAL-PONDS. _. D .j.. <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."Contractor's hiring or sub-contracting signature r <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 mus call for all uired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> 4�r��� ! <br /> FOR EPARTMENT USE ONLY <br /> Application Accspted,bDate (e Area <br /> Pit or Grout inspection by" T Date Final Inspection by Date g <br /> Additional C ments: S <br /> Applicant - Return allcopiesto: San Joaquin County Public Health <br /> j Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IEEE AMOUNT DUE AMOUNT REMiTTEO CASH RECEIVED BY DATE PERMIT NO. <br /> £H A-24(rtEY.118 a) <br /> A-211 Y <br /> EH 2b (p CJ s7 <br />