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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 EXPIRES 1 YEAR FROM DTE ISSIM <br /> (Complete in 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 made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> kJob Address '..����•_+L► 2,A + _ City t Size/Acreage <br /> XOwners Name Address <br /> 01 <br /> 79 <br /> Contractor Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ICULT ELL OTHER WELL PITS/SUMPS (} <br /> INTENDED USE TYPE OF WELL PROBL. R CONSTRUCTION SPECIFICATIONS <br /> Cl industrial ❑ Open Bottom anteca Dr Well E�,va Dia. of Well Casing <br /> El Domestic/Private �Gravel Pec n Tracy Type of Cas. Specifications <br /> I'I Public n Delta Depth of GrouType of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Wel! Diameter Sealing Material l3- Depth <br /> Al Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTIO (No seplic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of and 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 /> I S <br /> LL I <br /> 1r ! <br /> LEACHING LINE ❑ No. b Length of linea Total length/size <br /> FILTER BED t p Distance to nearest. Well Foundation l'1 Property Line <br /> SEEPAGE PITS l [Distance <br /> epth Sire Number <br /> SUMPS LI 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 Sin Joaquin County r,, <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 meaner as to become subject to workman's compensation laws of California." Contractors 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 must call to I required ispeclions. Complete drawing on reverse side. <br /> Signed Tide: Date: B" / <br /> 12 <br /> ` FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2 Area Z I <br /> Pit or Grout Inspection by Date Final Inspection by Data/ <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, P O Box 2008, Stich, CA 95201 <br /> FEE ME <br /> MOUNT DUE AMOUNT REMITTED CASH CK a RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 IAEV.an s. LO741EH 14.20 <br />