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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby me4e to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. c � ? ��,� ,Q.,O . //°°�� <br /> Job Address ���` � _ City Lot Size/Acreage iJcC <br /> t r• <br /> Owner's Name i Address @ Phone <br /> Contractor Address License No. Phon Q�l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION M Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_-1 Industrial © Open Bottom ❑ anteca Dia. of Well Excavation Dia. of Well Casing <br /> [.I Domestic/Private L1 Gravel Pack Lacy Type of Casing Specifications p, <br /> I'I Public I_l Other n Delta Depth of Grout Seal Type of Grout �3�9 <br /> I I Irrigation _..Approx. Depth I I tallern Surf ce Seal Installed by <br /> F Repair Work Done LJ Type of Pump�� H.P. �`' Stats Work Done ftows VV. <br /> ia <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Methodsal <br /> Distance to nearest: Well Foundation Propert ��� <br /> LEACHING LINE ❑ No. & Length of lines Total length/si LJ <br /> FILTER BED C_1 distance to nearest: Well Foundation Property LinMff1—"992 <br /> SEEPAGE PITS / I I Depth Size Number ENVIRONMENTAL H ALTH <br /> SUMPS l_I Distance to nearest: Well Foundation Propsrty � 'ICES <br /> DISPOSAL PONDS ❑ <br /> i <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 <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 n such manner as to become sub ct to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certilies the foil g: 'I certify that in the rforma a of the work for jn ,' <br /> his per it is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Ca ria." <br /> The applicant u t calk for I in c Complete drawinger de. <br /> T i <br /> Signed XTitle: dal 4 Date: <br /> FOR DEPARTMENT USE ONL / <br /> Application Accepted by Date r Area a <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., Pn Rn <br /> X 2009, Stockton, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CK f RECEIVED BY DATE �1 PERMIT'N0, <br /> . EH 13.24 WEV. /n SI T �� (�y�•�7 �! 7 92-_A07 <br /> EH to-2e .L <br />