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APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein de abed. ihIlk <br /> application is made in octipliance with San Joaquin County Ordinance No. 549 a d 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Service . <br /> 6 a <br /> Job Address Ciry LOC Size/Acreage _ <br /> Owner's Name t •D f^ Address Phone J1 <br /> Contractor - Address ice se No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R LACEMENTT[). DESTRUCTION'D Out.of Service Well D <br /> PUMP INSTALLATION O S STEM REPAIR O" OTHER C1 Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LI DISPOSALTLD. PROP:4LINE <br /> FOUNDATION- A ICU URE WELL OTHIN <br /> R.WELL ,PITS/SUMPS _ <br /> INTENDED USE (TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS I <br /> 71 industrial :OpenBottom� ❑71MAan Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private CI Gravel'Paclk O TYpe of Casing Specifications <br /> FI Public h1J Other 1� �, IDepth of Grout+Seal�t r ; Type of Grout <br /> I I Imgation ApproIf Depth` I 1 Eastern Surface Seal Installed-by`I- - 1 <br /> Repair Work Done U Ty ps of-Rump H.P. - State',WOrk-Dorne _ <br /> Well Destruction O Well Diameter 1 Seali Material E�DeptA,. - - <br /> V <br /> Depth Filler terial L Depth I <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/A DDITION I I DESTRUCTION I 'i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r , <br /> jInstallation will serve: Residence + CommerclialNi <br /> Number of living units: _ Number of bedrooms; <br /> t Character of soil to a depth of 3 feet: i + --� Water table depth <br /> SEPTIC TANK C D Type/Mfg Ar Capacity CapaJity.�2 U J--'N�`�mpertmenn <br /> ,Method of Dispose t <br /> �.PKG I TREATMENT PLT. D �- <br /> `�.,� f\ Distance to nearest: Well ! Foundation Property Line S <br /> t <br /> LEACHING LINE 'J ❑ No. 6 Length of lines'r ! oral length/sire <br /> FILTER BED D Distance to nearest: v Well Foun atiori_2_f_ Propeny Line <br /> r - <br /> SEEPAGE PITS 11 Depth l Siae Nu bar <br /> SUMPS LI Distance to nee est: wall Fountlation_ Property Line <br /> Y- <br /> I DISPOSAL PONDS D <br /> I hereby cenify that I have prepared this application and that the:work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> I <br /> les and regulations of the San Joaquin County ' . 7� _ <br /> Home owner or licensed agent's signature certifies the f611awing: '9 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any Person in such manner as to become subleZFPb workmen's compensation laws of California." Contractors hiring or sub-contracting signature <br /> `I{ certifies the following: "I cenify 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." {� V <br /> i The applic must c r alliequii Inspections. Complete drawing on reverse side. <br /> J Signed Title: � ' v ` Date: <br /> /2- ? -rlJ <br /> ! *N FOR DEPARTMENT USE ONLY <br /> p � ....,�. DI O"d Y Area <br /> Application Acceptedd by /: "' - ate / <br /> lhkL <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Date <br /> Additional Comments: -1 <br /> r <br /> t <br /> Applicant - Return e11 copies to: San ices, Environmental County Public Health <br /> Serv1 1601 Eee, zelto . Health Ferm2009,tStockton, <br /> E 16D1 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> ' FEE AMOUNT DUE AMOUNT REMITTED �As,f RECEIVED BY DATE PERMNNO. <br /> INFO <br /> tEa ta.ia IREV I'--' <br /> . r r <br />