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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1, 1 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 DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / A <br /> \ob Address 4,6 City Lot Size/Acreage !7L <br /> /4/_7__-3 ZZ,&Z <br /> Owner's Name /Z./ Address Phon <br /> Ar Contract Ad�4dress �i� i?/� 1V_4k1 - License N- `t f PhorC�09 �.V+ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Seyvice Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER toying Well �� <br /> DISTANCE TO NEARE C TANK SEWER LINES DISPO PROP. LINE <br /> FOUNDAT AGRICULTURE WEL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PR by <br /> SPECIFICATIONS <br /> n Industrial ❑ Open Bottom an, . of Well Excavation Dia. of WeN Casing <br /> [:I Domestic/Private ❑ Grave ❑ Tracy Type of Specifications <br /> 1'1 Public - ther n Delta Depth of Grout Sea Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Re ' ork Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I (No septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I, <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 subcontracting signature <br /> certifies the followin . "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 Cali <br /> The applican st call for all re%ared in ctions omplete drawing on averse side. f <br /> N Signed Ql V Date: <br /> FORDEPARTMENT USE ONLY <br /> Application Accepted by 2Date '(9::2 Area <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 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT D�U/E� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1211REV.iiM51 • ' W +� <br /> 4. <br /> EH t1.2e <br />