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e <br /> APPLICATION FOR PERMITS <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 J ^ <br /> IT EXPIRES 1_ YEAR FROM- DATE ISSUED <br /> (Complete is 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 Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address44�e, city tfiLot Size/Acreage <br /> )<1/Owner's NameYp 44P—er fi L Ia MQ1-Address Phone <br /> Owner's <br /> '("Contractor & s' 7S S License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP TION ❑ SYSTEM REPAIR ❑ OTHER ❑ oring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE <br /> FOUNDATION LTURE WELL WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ON SPECIFICATIONS <br /> C] Industrial 0 Open Bottom ❑Manteca is. of Wel ation Dia. of Well Casing <br /> Cl Domestic/Private Cl Gravel Pack cy Type of Casing Specifications <br /> I') Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth ( I Eastern Surface Seat Installed by <br /> Repair Work Don Type of Pump H.P. State Work Done r <br /> Well Destru n ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION INo septic system permitted if public sewer 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 feet Water table depth <br /> SEPTIC TANK. ❑ VMf Ca y No. Compartnlenta <br /> PKG. TREATMENT PLT. ❑ YYY E� Method of Disposal <br /> Disteeflig iTe tri 1,aN11� + a on Property Line <br /> LEACHING LINE L1 N An �f rFF ff�I ��GG 0 ,LTotal length/s+ze <br /> FILTER BED Cl Dis emlcjtt �: VMII ITG4li I�Fpgd tion Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordanctb with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homeowner 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 <br /> certifier 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 applica t s call for all rir inspections. Complete drawing on reverse side. <br /> ' <br /> )(Signed X Title: _. C - <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by &6m kAA Z� Date S- f b 1 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 O Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOU 1NT;�REMITTED GASH RECEIVED BY DATE <br /> _ �iPERMIT'NrO. <br /> . £H 13-211REV.i/++SrCE) ^� V a� _(U,11 1i — L{3 <br /> EH i1-26 l Ilii <br />