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APPLICATION FOR PERMIT <br /> SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES �- <br /> ENVIRONMENTAL HEALTH DIVISION �� <br /> 1001 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> �3 <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> l <br /> YJob AddresshS�I City Lot Size/Acreage <br /> Owner' Name . fne-adoqddress _� �+ t7~ _ _ Phone <br /> Contractor Address 7' S: "y1,�2.1 License No. Z sLzo V_ Phone <br /> TYPE OF WPL MP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION 0 Out of Service Well <br /> ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR <br /> FOUNDATION AG RE WELL OTHER PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA N SPECIFICATIONS <br /> n Industrial 0 Open Bottom ca Dia. of Well Excavatio Dia. of Well Casing <br /> N Domestic/Private ❑ Gr L7 Tracy Type of Casing Specifications <br /> F1 Public [I Other Cl Delta Depth of Grout Seal a of Grout <br /> + l Irrigation ��ApproK. Depth C I Eastern Surface Seal Installed by <br /> Repair Work Done O 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 1 REPAIR/ADDITION i I DESTRUCTION lNo 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 of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ T,ypelMfg Capacity No. Compartments = ' <br /> PKG. TREATMENT PLT. 0 <br /> 11 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> p <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> d <br /> a <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS L) Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <br /> 1 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 mariner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall'empioy persons subject to workman's compensa- <br /> tion laws of California." P <br /> :i <br /> The applicanti all re inspections. Compiete drawing on reverse side. <br /> Signed x Title: ���_ Date: <br /> T�WDEPAATIMEINT USE ONLY <br /> Application Accepted by I ILA Date ^ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> ,I I <br /> Additional Comments: CA <br /> r <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 />[ INFO AMOUNT DUE AMOUNT JREMITTED CK 9 CASH RECEIVED BY DATE PERMIT'NO.EH 13-74 ��. <br /> 3-1 <br /> ii EH 14.26 � <br /> (REV. 4 4V l tOv 8 <br /> j li <br />