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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSRED <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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> Services. <br /> �5� y <br /> Job Address 'A City S/ rof Size/Acreage <br /> Owner's Name Mj '� Address I g 7-1V eSI Phone — S/ <br /> A(4 AJ4 AP 1 <br /> Contractor Address License No. `v . Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Seftice Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICULTURE EL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF W L PROBLE AREA N UC ON SPECIFICATIONS <br /> C7 Industrial ❑ Open 1}4 om ❑ Mant ca Di el Excavation Dia. of Well Casing <br /> Cl Domestic/Private Ll Gravel ack ❑ Trac T p of C sing_ Specifications Q <br /> l'1 Public 1-1 Ot 1-1 a pth o Grout Seal Type of Grout { �► <br /> I I Irrigation 'Approx. D th l 1 stern urfac Seal Installed by <br /> Repair Work Done ❑ Ty of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter sealing Material ale Depth <br /> Depth Filler er a pth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I Y REPAIR/A.DDITN OE RUCTION I I (No septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: ResidenceL Commercial_ Other <br /> Number of living units: r Number of bedrooms �,/ {/ I� <br /> Character of soil to a depth of 3 feet: , Xr u')i�[` ter table depth <br /> SEPTIC TANK. Type/Mfg _. _ Le�L Capacity � No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal 4F4 C <br /> Distance to nearest,- Well Az/" Foundatio Property Line__ llR <br /> LEACHING LINE Qr-No. b Length of lines - Total length/size �= b, 140 ZXZ <br /> 1 <br /> FILTER BED El . Distance to nearest: Well�//I Foundation �� Property Lina <br /> SEEPAGE PITS (W'Dept Size Number <br /> SUMPS LI Distance to Hearst: Well Foundation �5� Property Lina <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.regulatkm of the San Joaquin county <br /> Homs 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: "1 cartify 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 /> The applicant roust call for ail required inspections. Complete drawing on reverse side. <br /> Signed X. Title: —0 /� Date: I I <br /> a;Fnj�-AAURXA- 11SE ONLYApplication Accepted by CAw� _• Date <br /> Pit of Grout Inspection by Date Final Inspection by Date <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'O Sox 2009, Stkn, CA 95201 <br /> INFO ACKI <br /> MOUNT yyDUE AMOUN1T REMITTED CASH RECEFVED BY DATE PERMIT-NO. <br /> . EM 13.24{pEV,r i>,s! C r✓fI I! -- <br /> EH 11•Ia <br />