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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, .PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEARRMDTEISSPEP <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban.Joequin County for a permit to construct and/or install the work herein described. This <br /> application is grade in compliance with San Josqufn,-County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. (rj <br /> Job Address w' City Got Size/Acreage <br /> Owner's NameI Address ��' Aais) Phone <br /> & - N.ff i <br /> V 109:20 <br /> Contracts L p Address i/ License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT .. DESTRUCTION ❑ Out of Service Well <br /> j. PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE <br /> z--�FOUNDATION4----- A-GRtCULTURE WELL_ ---^-"-='OTHER-WELL-t!" ��PITS-/SUM PS-t <br /> INTENDED USE' TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial E ❑ Open Bortom . ❑ Mgntsca Dia. of Well Excavation Dia. of Well Casing <br /> -DO-w <br /> Cl Gravel Pack C1 Tracy Type of Casing_ Specifications <br /> Public 11 Other n Delta Depth of Grout Seal T pe of Grout �] <br /> I I Irrigation __._.Approx. Depth I I Eastern Surface Seal Installed by C2 <br /> Repair Work Done L] Type of Pump H.P. State Work Done _Zg DAililud <br /> Wall Destruction '0 Well Diameter Sealing Material i Depth <br /> Depth f Filler Material i Depth +� <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> IN <br /> available-within-200 <br /> Installation will serve: Residence= <br /> Number of living 4!4s: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t '° t # yk <br /> WatjCf&N <br /> :SEPTIC TANK' 17y Type/Mfg .,.,_ ll_ Capacity' It No. <br /> PKG. TREATMENT PLT. Cl Met r <br /> ' <br /> Distance to nearest: Well Foundation # Property Lir �A? <br /> � # - n` .. it � JJ { <br /> LEACHING LINE ❑ No. b Length of lines f B Total-I rig to h <br /> v V <br /> FILTER BEs? y-,C7�. Distance to nearest: well Foundation PSRH DIVISION <br /> t .. d <br /> SEEPAGE PITS } 11 Depth Size Number' . <br /> SUMPS L11 Distance to nearest: Well Fou <br /> ndationProperty'Linfa <br /> =-DISPOSAL PONDS,�- Q sem- <br /> - � --- `r..' +iia 'k. ri�.,.��- ►. �►#. a-A,. .-. - <br /> I hereby certify that I have prepared this application and that the work will bi done-in-accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations'of the San Joaquin County k , r <br /> Home owner or licens&d agent's signature certifies the following: "I certify that'in the performance of the work for which thiatpermit is issued, I shall not <br /> employ any psrao r wch manner as to become wbjett to workman's co mpensa't_ion-laws of California."Contractor's hirin`g.or sub-contracting signature <br /> certifies the f : "I certify that in the performance of the work for which this permit•is is:ue`d; I shall employ"peisons.sdbject to workman's compenss- <br /> tion laws of al' }r�-�--.... } <br /> r. , <br /> The applies call for all insp <br /> requi ect' Ca late drawing on re a `side. <br /> - - Title: -- Data: <br /> - �.., ».,.....� —fOR-DEP.ART,M USE=ONLY j.'4-,,-,_ -. <br /> Application Accepted by Data - i Area <br /> Pit or Grout Inspection by Date Final Inspection by Date r7t3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, -R.? Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AM�ODUrNT REMITTED CK RECEIVED BY DATE �]PyERMIT'NO. <br /> FH 1 <br /> • <br /> EH3-24 <br /> �`3.2�tAEV.�ixer � 7"� 0-D LS�� 3 <�v <br /> sryJ� <br /> i <br />