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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 952¢� <br /> ' >� <br /> PERMIT EXP RES 1 YEAR FROM DATE <br /> rID <br /> I (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 camPliance with San Joaquin -County Ordinance No, 549 and 1662 aad the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Z G' . p10 <br /> Job Address f r7 /`Q City LT rof Size/Acreage <br /> Le .� M � e.. 11 , y - <br /> Owner's Name Address �'- (d�� Phone Z� <br /> Contractor S Q L Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wel.1 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C.1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT LL <br /> INTENDED USE TYPE OF WELL P 4,.. N5 IJ I I S <br /> n Industrial ❑ Open Bottom 0 a ec a. o It t1cavat n Dia. o!Well Casing _ <br /> L) Domestic/Private ❑ Gravel Pack L7 r ' ' 5pecitf W-11 <br /> I'I Public 1:7 Other !�lD �n iations <br /> aM1100 Gf uP�S a r <br /> I, Mra (� ��pp Type of Grout i <br /> I 1 Irrigation __ Approx. Depth EMT Oelno li9M� �JffIh�a�kl� �A � <br /> Repair Work Done U Type of Pump <br /> Well Destruction C) Well Diameter "J ` "s� ate r epth llork Done <br /> Depth Filler Material b Depth " <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! DESTRUCTION i 1 (No septic system permittee if public sewer is <br /> available within 200 feet.) l, <br /> Installation will serve: Aes encs v Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ A'"i l--)I I6 i/ \ <br /> Water labia depth � <br /> SEPTIC TANK ❑ Type/Mfg P Capacity___ C9 c7 Q No. Compartments l <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I <br /> Distance to nearest: Well Foundationt <br /> Property Lina <br /> LEACHING LINE lb"o-No. & Length of lines Z D =7 <br /> g Tptai length/si <br /> FILTER BED n Distance to nearest: Well 1 4 1 Foundation j b Proper <br /> SEEPAGE PITS I I Depth Size <br /> ._._ Number� <br /> SUMPS LI Distance to nearest: Well <br /> Foundation Proper <br /> DISPOSAL PONDS p \ <br /> I herebycertif that I have p pp <br /> Y prepared this application and that the work will be done in accordance with Santncounty ordinances, state laws, <br /> rules and regulations of the San Joaquin County anZi--�,�- <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> 1 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 applican s all I re d insPections. Complete drawing on reverse side, <br /> ;fined Title: W Date: <br /> FOR DE ARTIMENT USE ONLY <br /> plication Accepted by Date \' �1��- <br /> F Area <br /> Grout inspection by Date Final inspection by <br /> Date <br /> nal Comments: — <br /> f <br /> int - Return all copies to: San Joaquin County Public health .T <br /> Services, Environmental Health?Permit/Services <br /> 1601 E. Hazelton Ave., P O.Box 2009, Stockton, CA 9';201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> IN ICASH RECEIVED 9Y DATE PERMIT'NO. l <br /> R �fir''g^` El �a' �a <br />