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APPLICATION /\\� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION N 0 W�cA, <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU • 0 <br /> I (Complete in Triplicate) <br /> Application is hereby made,to Sam !Joaquin County fore permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549_eirid 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �� City Lot Size/Acreage <br /> 41 , 1 fr <br /> Owner's Name Address -g�l� Za �+e' -�`� Phone <br /> 't <br /> Contractor Address I J License No /�Phone <br /> TYPE OF WE UPUMP:--- _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o Out of Service Well ❑ <br /> PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> OTHER WELL PtTS/SUMPS _. <br /> INTENDED USE ' YPE O OB A ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open prBomtt�'m +' ❑ `M�aanteca ,I �I11 of�4 ell Excavation Dia. of Well Casing <br /> a[:l Domestic/Private ❑ G JAP Pkt �m Y Tr`alc�X it MIQO Tell <br /> Specifications <br /> i, 'Public I=, wwk-being C"Wed or inp8letedrout.Seal Type of Grout f <br /> 4 1 1 Irrigation _ j�'rt1 1.I-'E ea�rr 1, uric,,Weal Installed by <br /> Repair Work Done C3 Type of Pumtprllth.�t��l,��r� State Work Done _ <br /> Well Destruction ❑ Well Diameter , Sealing Material 8 Depth <br />.f Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDiTION I ) DESTRUCTION lNo septic system permitted if public sewer is <br /> E + available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other --• <br /> Number of living units: Number of bedrooms <br /> w <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg i' ° "" "" Capacity .. No. Compartments <br /> PKG..TREATMENT PLT. ❑ { Method of Disposal a <br /> A Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation e Property Line <br /> SEEPAGE PITS 11 Depth Size Number } <br /> SUMPS + Ll Distance to nearest: Well Foundation .t Property Line <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 i ` -,— <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, 1 shall'employ persons subject to workman's compensa- <br /> tion laws of Catifornls.' f <br /> The applicant must call for all reqyirqd insPect' S. Complete drawing on reverse side. ' f <br /> t <br /> Signed X 24Z - °�Titfeit:�'1' l Date: •^ -�,__7/ <br /> > FOR PARTMENT USE ONLY <br /> i <br /> Application Accepted by CDA" - -Date�e� Area �f <br /> Pit or Grout Inspection,by Date —Final by Date <br /> Additional Comments: ` <br /> Applicant - Return all copies to; -'San Joaquin County Public Health Services <br /> t Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'N0. <br /> + ER 13-24(REV.1/"s1 co eo -A <br />