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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 /> P 0 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 described. This <br /> application In 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 /> Z71 <br /> Job AddressCity <br /> � i11r f,!l� 1- v� _ <br /> _ I.oL Size/Acreage <br /> C 0�- �vk - — <br /> Owner's Name ✓L�E%�L/ Address phor>8`� 1 <br /> Contractor ` d sr� License No. PhoneUv-G ' w ' <br /> TYPE OF WELL/PUMP: N ELL O WELL:REPLACEMENT Fl DESTRUCTION Cl Out of Service Well O <br /> PUMP INSTALLATIO M REPAIR O OTHER O Monitoring WellDISTANCE TO NEAREST: SEPTIC TANK S LINES DISPOSAL F ROP. LINE <br /> FOUNDATION AGRICUL L WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA R ON SPECIFICATIONS <br /> Fl Industrial O Open Bottom ca Dia. of Well Excav Dia. of Well Casing _ <br /> I I Domestic/Private Cl Gravel O Tracy Type of Casing Specifications <br /> 1'1 Public ther Fl Delta Depth of Grout Seal Type of Grout <br /> I I IrriOation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Healing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION (No septic system permitted it public sewer is <br /> available within 200 feet.) A n <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS II Depth Size _ _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 t <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 /> tion laws of California." <br /> The applicant mu all for al require i sppections. Complete drawing on reverse side. <br /> 'Signed X Title: -SA-•`K S;t V'P-t-S __ Date: S_� �q 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date , ( AreaQrr3'�� <br /> 7 e� <br /> Pit or Grout Inspection by Date Final Inspection by Dat .94 <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> EH13-24IREV. q-72 <br /> �, �• // rl� •w <br /> _EH 14.2E <br />