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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468—ft473q-"­0 <br /> YEAR PROM PATE 15SUED <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 <br /> Health Services. �j <br /> Job Address ._ f `� f � J• - City ' ` 0"ot Size/Acreage Z <br /> Address ���U Phone y <br /> Owner's Name � �� <br /> Contractor �/ Address License No. '__' ,"' Phone <br /> /l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Mon taring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP NE <br /> UNDATION AGRICULTURE WELL OTHER WELL TS1SUMPS <br /> INTENDED USE TYPE OF WE OBLEM AREA CONSTRUCTION SPECIFICA <br /> f� Industrial O Open Bottom ❑ Man Dia, of Well Excav Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy y Specifications <br /> p Public C1 Other ❑ Delta pth of Grout Type of Grout <br /> 0 Irrigation ,_..Approx. Depth CI Eastern Surface Sell Installed by <br /> Repair Work Done CD Type of Pump H.P. State Work Done <br /> Walt bestruction O Waft Diamet sealing Material i Depth Q <br /> Depth Piller Material & Depth {/1r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION G INo septic system permitted if public sower is 0, <br /> available within 200 foot.) <br /> Installation will serve: Residence-y- Commercial of - <br /> Number of living units: Number of bedro ms <br /> Character of soil to a depth of 3 feet: Water table depth } <br /> SEPTIC TANK ❑ Type/Mfg ¢" L- Capacity /66V_ No:Compartments <br /> PKG, TREATMENT PLT. 0 �-^ Method of D.s°sal <br /> Distance to nearest: Well ``-�✓ FoundationAProperty Line %? <br /> LEACHING LINE -eNo. &.Length of lines Tata) length/size <br /> FILTER BED C'1 Distance to nearest: Well Foundation Q Property Line <br /> SEEPAGE PITS I I Depth 1r Sirs Number <br /> SUMPS Ll Distance to nearest: Well Foundation 2 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 <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 r <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 fotlowinq: "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 must c 11 all requ spections. Complete drawing on reverse side. ) <br /> 7/Signed X�. —____-- Title: � -- — Date- <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by 41007Date Z~ ` Area i <br /> Pit or Grout Inspection by Date Final Inspection by Date ` <br /> a. <br /> Additional Comments: — <br /> I <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEAW7'NO, <br /> INFO I I CASH <br /> . EH17•NEREV.>>nsr <br /> 114 All !SD 1 S-S 191--a. 7 <br /> tH:62111 <br /> 1 <br />