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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 NOW <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS PED {gyp CW c� <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the cork here n 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 Services. <br /> Job Address v F :17Z City Lot Size/Acreage <br /> Owner's Name _ d ss ' Phone <br /> Contractor <br /> cess r I cense No. Phone <br /> TYPE OF WELL/ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out o Service Well ❑ <br /> PUMP INST LATION ❑ SYSTEM REPAIR El OTHER ❑ onitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. OP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P LEM AREA CONSTRUCTION SPECIFICATION <br /> C] Industrial ❑ Open Bottom ❑ Ma ca Dia. of Well Excavation Dia- of Well Casing <br /> �.1 Domestic/Private Cl Gravel Pack Ll Tracy Type of Casing Specifications <br /> F1 Public 1-1 Other n Delta Depth of Grout Sea Type of Grout <br /> 1 Irrigation —Approx. Depth 1 ) Eastern Surface Seal InX.Iled by <br /> Repair Work Done U Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing ter & Depth <br /> Depth Filler Mat ial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AD ION DESTRUCTION INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial her <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. ❑ Method of Disposal <br /> Distance to earest: Well Foundation Property Line <br /> Is <br /> LEACHING LINE ❑ N Length of lines To[al gth/size <br /> FILTER BED ❑ istance to nearest: Well Foundation ` party Line <br /> SEEPAGE PITS I I Depth Size Number' <br /> SUMPS U Distance to nearest: Well Foundation . Property ' e <br /> DISPOSAL NDS ❑ <br /> I hereb/a rtify 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 d 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, 1 shall not LL <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 1 <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 /> The applicant St for requ' d ' spec ions. Comp) to drawing an reverse side. <br /> Signed XW1.� <br /> Title: nOate <br /> FOR DEPARTMENT E ONLYIlk <br /> , <br /> Application Accepted by a., _-__ Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 B. Hazelton Ave., P 0 Box 2909, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED /��CK# fRECEIVED BY DATE ("� [ PERMIT-NO, <br /> + CH 13-24iREV.i/wei ©� &) t 111 1� tlr �{�-(� <br /> EH 14.26 4 �r"� V 1r� ! L i v <br />