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_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <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 Is made in coupllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �� ����� J �' City Lot Size/Acreage <br /> Owner's Name �f�_7 Address � �= Tions 2 <br /> Contractor /� � �7/'GE'7e4ddress /_2 License No Phone��6 �� S <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT P DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitor Well C7 <br /> DISTANCE-TO NEARES-"EPTIC TANK SEWER LINES DISPOSAL FLD. PR . <br /> FOUN-(YAY-iO AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL P BLM AREA CONSTRUCTION S�PECI-FIIC- <br /> fl Industrial ❑ Open Bottom ❑ Trant—eca� —Dia-of Well E avafion Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack ❑ Tracy lye Casing Specifications <br /> M Public CI Other 0 pelta-- Depth of Grout Seal Type of Grout <br /> U Irrigation _.Approx.-Depth ❑ Eastern Surface Seal Installed by \ <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: rr`_ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg < ` v� ^ Capacity No. Compartments 6 <br /> PKG. TREATMENT PLT. Cl C Method of Disposal <br /> /;7SDistance to nearest: Well � Foundation �_ Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> g � �l� � Total length/size <br /> FILTER BED C) Distance to nearest: Well ��S Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sired Number <br /> SUMPS LI Distance to nearest: Well � Zn Foundation �` _ Property Line /25,"G i <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 San Joaquin County C <br /> Home owner or licensed agent's signature certifies the following: "I certify that in thu 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica71U' <br /> x c INor all r ed inspections. Complete drawing on revers ide. <br /> Signed w _ Title: �' � Date: <br /> FOR DEPARTMENT USE ONLY Q <br /> Application Accepted by Dat o-� O ' �� Area _ <br /> ,LRit or Grout Inspection by Date- -F( Z Final Inspection by _I/ 7 ��,+� _ Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> K if <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED 1ASH —RECEIVED BY DATE PERMIT NO, <br /> •'EH i3241RV, A 5 "� i <br />