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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PAYMENT <br /> 1601 F. HAZELTON AVE. , PHONE (209)468-3420 �������� � <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YEAR FR M DAT S E P 181990 <br /> (Complete in Triplicate) SAN JOAQUIN COt1NT �S � <br /> Application is hereby <br /> made San Joaquin County for a permit to construct and/or install the work��MMIALZ �ON <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Ru <br /> Joaquin County Public Health Services. �^. <br /> X700 ZCity C-� Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> .. _ ` Address Inv Ty4 Phone Ll <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION ❑ out Monitoring Well or service Well.'�- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ISO � SEWER LINES X00 f DISPOSAL FLO.i ' = PROP. <br /> LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> eca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> n industrial ❑ Open Bottom C] Mant <br /> t7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public C-7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction C1 Wail Material & Depth Weil Diameter 1•f <br /> Depth Filler Material & Depth q+ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is f <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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED CJ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS CI 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 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, t 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 /> 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 Calilorni <br /> The applica mut I f r a ed Qr+-re s ctions. Complete drawing arse side. <br /> i Signed X Title: Data: i3 <br /> FOA DEPARTMENT USE ONLY a pJ <br /> Application Accepted by Date 7 a _ Area + <br /> Pit or Grout Inspection by Date Final Inspection by Date 1 <br /> 4 Additional Comments: - - NETZE V &1e <br /> Applicant - Return all copies to: San Joaquin County Lblic Health <br /> E Services, Environmental Health Permit/Services <br /> 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> N <br /> PE£ AMOUNT Dt1£ AMOUNT REMITTED rCK XJ RECEIVED 8Y DATE PERMIT ND. <br /> INFO <br /> i g 1F Q� p�2S I3 <br /> i EM 13-24 IRFY.t i n sl <br /> z7 �o �� <br /> l EH 34.26 <br /> i <br />