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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)468--3420 <br /> F41 P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ISSEED ,,** <br /> (Complete in Triplicate) 0") <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> ` Joaquin County Public Health Services. <br /> k � <br /> Job Address 0 A City Lot Size/Acreage <br /> Owner's Name_,. Address L a •/ Phone <br /> Contractor ddress License No. <br /> TYPE OF ELLIPUMP: NEW WELL ❑ WELL REPLACEMENT M_ DESTRUCTION Ci Out of Service Well ❑ <br /> W <br /> PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION,. AGRI LILAR9 WELL OTHER WELL PITS/SUMPS <br /> G INTENDED USE TYPE OF WI'L`L PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom, . ❑ M eca Dia- of Well Excavation Dia. of Well Casing <br /> k. <br /> EI Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> I'1 Public 1.1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —..Approx. pth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump P. State Work Done— <br /> l- <br /> Wall Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> tl <br />` TYPE OF SEPTIC WORK: NEW INSTALLATION I I R .AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> j available within feet.) <br /> Installation will serve: Residence_, Commercial____ ther <br /> + Number of living units: Number of bedrooms f <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 LineFi <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Tota eCgth/size N\ <br />+ FILTER BED ❑ Distance to nearest: We <br /> a <br /> SEEPAGE PITS 11 Depth Siza umber <br /> ' SUMPS 0 Distance to nearest: Well tion Property Line <br /> i DISPOSAL PONDS ❑ . ' <br /> fl 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. 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 /> F tion laws of California." <br /> The applicantust call for ired in clions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> P, FOR DEPARTMENT USE ONLY <br /> Application Accepted by bate ' Area <br /> Pit or Grout inspection by Date _ Final Inspection by J — Date <br /> r Additional Comments; - <br /> 1 <br /> Applicant - Return all copies to: San Joaquin County Public Health— <br /> Services, h�vironmental-Health Permit/Services ' <br /> Fi 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTER CA H RECEIVED 9Y DATE LPERmj-,N0.' <br /> �. EH 13-24IREV.+i45l =y <br /> 'EH 4.25 - YY <br />