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APPLICATION FOR PERMIT <br /> 4r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3601 p•0BOX 2009�, STOCKTON, CA <br /> V095201-3420 <br /> i <br /> XP RES 1 SITAR FR M D TE <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 compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San / <br /> Joaquin County Public Health Services.- f/ 5- `,1�*L�t/ , fZ� <br /> `/J/ FT / City Lot Size/Acreage <br /> Y Joh Address - / <br /> j j(Owner's Name 9-ow1oddress <br /> 8 Phone <br /> k �-Phone <br /> 1CContractor <br /> +'.t��(1. a Address---L( --�- <br /> ce Well <br /> TYPE OF WE NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION ❑ a't oonitoring Well <br /> -SYSTEM REPAIR ❑ OTHE <br /> PUMP INSTA Y _ DISPO5A LINES PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULLL ER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM ARE STRUCT ECIFiCATIONS <br /> ation Dia. of Well Casing <br /> Cl Industrial El OpBn Bottom- , t ca Dia. of Well Excav <br /> I C1 Tracy Type of Casing Specifications_- <br /> Cl Domt I esticlPrivate ❑ Gravel P Depth of Grout Seal of Grout <br /> I'I Public er Delta <br /> I i Irrigation �..Approx.Depth l Eastern Surface Saul Installed by A <br /> H.P. State Work Done , 4 <br /> Re rk Done f3 Type of Pump Sealing Material Depth � <br /> ' Well Diameter Well Destruction ❑ iFiller Material 6 Depth UJ VF <br /> k Depth <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I avail bleNo rwithin 200 feetstem .) if public sewer is ( n <br /> M <br /> f <br /> Installation will serve: Residence—', Commercial-==--Other---�-�-- � <br /> I Number of living units: Number-of..bedrooms Water table depth <br /> f Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/-Mfg—= Capacity F ) <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0 <br /> Distance to nearest: Well Foundation Property Line <br /> _ � f <br /> Total length/size <br /> LEACHING LINE ElNo, & Length of lines <br /> i FILTER 85D C1 Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> i' SUMPS <br /> Foundation Property Line <br /> 0 Distance to nearest: Well <br /> DISPOSAL PONDS <br /> r I hereby.cenify that I have prepared this application and that the work will be don cccordance with Sart 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 shalt 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 /> i The applica ust call for ail required ins tions. Co Iete drawing on reverse side. / <br /> S <br /> Title: <br /> igned Date: <br /> r FOR DEPARTMENT USE ONLY /r <br /> Date .Area <br /> Application Accepted by , <br /> �DaleFinal Inspection by <br /> e Date <br /> Pit or Grout inspection by <br /> t Additional Comments: <br /> ?Applicant - Return all. cop7_:::- <br /> eSan Joaquin County Public Health <br /> Services, Environmental-Health-Permit/Services.-- <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE PERMIT'NO. <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED: t `CASH HEGEIVED BY � rpATE � <br /> ME.- .,, <br />