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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> L 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> MNIT EXP RES 1 YEAR 'FROM DA E ED . <br /> (Complete in Triplicate) <br /> f 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 campliancd with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> � � <br /> Job Address �15R 3 O <br /> pCity Lot Size/Acreage <br /> r + <br /> Owner's Name Address _ Phone <br /> Contractor�� e AddressC2Li ?�c�.'� -p <br /> cense Nt�_7� �Phon3`s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'D OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: TANK SEWER LINES DiSPOSA <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE <br /> _ SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation _ Dia. of Well Casing y <br /> C:1 Domestic/Private C1 Gravel Pack C] Tracy Type of Casing .. cifications <br /> I'I Public (DO fl Delta Depth of Grout Seal Type o t <br /> i I Irrigation —Approx. Depth ( 1 Eastern Surface Seal'lnstalled by <br /> Repair Work a 0 Type of Pump' H.P., <br /> State Work Done_ <br /> Well D ruction ❑ Well Diameter! Sealing Material & Depth <br /> Depth Filler Material &Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION_I I DESTRUCTIO lNo septic system permitted if public sawer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other `" G <br /> Number of living units: Number of bedrooms ,; 9 <br /> Character of soil to a depth of 3 feet: kr j Water table depth (,V <br /> SEPTIC TANK. ❑ Type/Mfg Capacit L�„ <br /> Y No. Compartments <br /> PKG, TREATMENT PLT. ❑ .' � "�""'—_� 'N}Method of Disposal <br /> Distance tonearest: Well Foundation -property Line <br /> LEACHING.LINE Cl No. & Length of lines _ <br /> FILTER BED Total length/size <br /> ❑ Distance to}nearest: Well� Foundation.—- --Property Line , <br /> SEEPAGE PITS 11 Depth Size <br /> Number Property Line <br /> SUMPS LI Distance to inearest: Well Foundation ` 1 <br /> DISPOSAL PONDS ❑ � r � <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 .4 <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 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 California," <br /> The applicant ust call for all required inspection. Complete drawing bn'reverse side. <br /> Signe <br /> Title: Date: a2 <br /> 1 <br /> f . FODEPARTMEN�USE OfVLY d <br /> Application Accepted by Date <br /> a <br /> Pit or Grout Inspection byDate Final Inspection by �' ?3 , <br /> Data <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 /> EEE AMOUNT DUE AMOUNT REMITTED 1 <br /> INFO CASH RECEIVED BY DATE PERM17'NO. 4e <br /> + EH 13.21 IREV,i i R 5) � <br /> EH;ate r �.ry-� i <br /> l (J 2 . <br /> i <br />