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APPLICAT10N FOR PERMIT �t J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION A\, 7o P O BO% 2009, STOCKTON, CA 95201(209) 468-3447YEAR 1�R0ld ISSUED <br /> (Complete is Triplicate) <br /> Application is hereby rands 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. 5119 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health, Services. <br /> _ C /Il• L[1/NpsaR <br /> �JOb Address _l_ , p ! ,.-_ City � �/VLot Size/Acreage <br /> Owner's Name�t �_� /©�pnoll Address u 0 Lbf 1WPh <br /> one <br /> Contractor C)UD Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: d- NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NE SEPTIC TANK SEWER LINES DISPOSAL FLD. P LINE <br /> F TION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF W PROBLEM AREA CONSTRUCTION SPECIE DNS <br /> Cl Industrial ❑ Open Bottom nteca Dia. of �Eion Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy T Specifications <br /> ❑ Public ill Other 0 Delta th of Grout Seal Type of Grout <br /> Irrigation Approx , depth ern Surfac til Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction D Wall D' ar Sealing Material A Depth <br /> pth Filler Material b Depth <br /> YPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION (No septic system permitted if public sewer is r <br /> y available within 200 last.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: t Number of bedrooms s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity v No. Compartments <br /> P TREATMENT PLT. 0 Method of <br /> ,. ��A,� Disposal <br /> r <br /> Distance to nearest: Welt. Foundation Property Line <br /> _ t <br /> LEACHING LINE Cl No. b Length of lines - Total length/size <br /> FILTER BED is Distance to neatest: Welt ._Foundation Property Line <br /> k <br /> SEEPAGE PITS I I Depth Size'/- Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> i <br /> I hereby cenity 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 w �,_3' <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, I shali employ persons subject to workman's compensa- <br /> tion laws of California." !! <br /> fy, P i <br /> {/ The applic ust call for all s Inspections. Complete drawing on reverse side. <br /> f[ Signed Title: W � f J/� I✓'/ I <br /> Date, - ----- <br /> MENT USE ONLY <br /> - _ .�.ill' ,._..._&;�Z�P�RT r <br /> Application Accepted by Date !�' L Area <br /> C r <br /> Pit or Grout Inspection by Date Final Inspection by Date 11 . <br /> 1 <br /> Additional Comments: <br /> Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 + <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RE{EIVEO BY PATE PEAMIT'rJO. X <br /> INFO A <br /> CSH <br /> • €H 14.2111 .irn � <br /> 51 • 3 �L <br /> J`. Ifs —� 1 ' l 6�-'U1�� <br />