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APPLICATION FOR PERMIT <br /> 67 85 C)'al�p,� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> q 5 qv c Ghl�"^"" ENV I RONM ENTAL HEALTH DIVISION <br /> p <br /> -It �-� 445 N SAN JOAQIIIN, PHONE (209)468-3420 <br /> �' 0 P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1—YEAR FR M DATE <br /> (Complete in 'triplicate) <br /> Application-is hereby made to San.'Joaquin County for a permit to construct and/or install the vork herein described. This <br /> I application is made in compliance;vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City C Lot Size/Acreage <br /> Job Address ,�,/ (��, <br /> if owner's Name <br /> �� ( LO r�-. Address o s! M� '`�`- Phone <br /> S_ ,� - <br /> Contractor pf" ddress v License Na � Phone <br /> TYPE OF WELL/PUMP: NEW ELL WELL REPLACEMENT/%QDESTRUCTIO O^t MoService Well 0 <br /> nitoring Well L7 <br /> PUMP INSTALLATION,�..,O�pp SYSTEM REPAIR ❑ ., ' OTHER 0- <br /> 7f <br /> DISTANCE TO NEAREST: SEPTIC TANK _ 'L -- SEWER LINES DISPOSAL;fLD,_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ',w. <br /> lC] d END ❑/Open Bottom O anteca Dia. of Well Escavati n Dia. of WaN Casing <br /> {Xpomestic/Private rf}r�Gravel Pack Tracy Type of Casing_ Spaci(ications <br /> ✓✓✓ "` I/ Type of Grout p <br /> 1 l Public I-I Other �l Delta Depth of Grout Seal <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. S to Work Done <br /> ' Sealing Material i Depth r r <br /> Well DestructionX51 Wall Diameter <br /> [[[ �" Depth _ a _ Filler Material i Depth <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION.I 1 DESTRUCTION I I (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*ON to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/ftCapacity No. Compartments <br /> PKG. TREATMENT PLT.0 Y IMethod of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/size <br /> f FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> t SEEPAGE PITS I I Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property line <br /> DISPOSAL PONDS D <br /> I hereby certify that I hay*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 /> Borne owner or licensed agent's signature conifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ sny person in such manner as to become subject to workmen's compensation laws of California,"Contractor's hiring or sub-contracting signature <br /> cartifiss the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's eonipensa <br /> i tion laws of Celilornia." <br /> The applicant t I for r tnspactions. Co plate drawing on/rpres side. <br /> Signed Title: � Date. <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date t��` _ -- Area 07 A 0, 4 <br /> S _ <br /> Pit or Grout Inspection by Date Final Inspection by r��'r'p <br /> Date <br /> s LLQ W,--_4L is No-r D&6T?-OBJ D NQ&)• PW ImnagF MISCD 70 MWm 7/}t1V Q G.L4Gc., <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE j AMOUNT REMITTED ECEIVED BY d TE PERMIT"NO.ILI <br /> tEv51 ! �' 3; <br /> . Eli 1521 lt .,tw1'. � . <br /> EM 14.20 (� <br />