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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVTCkS_'__ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br />` PERMIT 9MIRES ] YEAR OM DATE ISS�J� <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 cowilance with.San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 4:i-* 4 f. _ <br /> ,lob Address <br /> Z �f "02( < --itJJ City r i Lot Size/Acreage d � <br /> F �3�/moi V Address Phone 3T / 16 <br /> Owner's Name <br /> r <br /> contractor <br /> D,7aJZ&� ��C� Address ICJe' �� ' r =- /License ho. _ hone 5� S <br /> TYPE OF WELL/PUMP: % NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Se ce Hell ❑ <br /> PUMP ALLATION ❑ SYSTEM REPAIR ❑ OTHER toring Well [.I <br /> DISTANCE TO NEAREST: SEPTIC TAN .� SEWER LINES" rr""''' "" " DISPOS - "PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS w <br /> INTENDED USE TYPE OF WELk\ PROBLEM A RUCTION SPECIFICATIONS <br /> k nindustrial ❑ Open Bottom ` E) Man Dr Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel.Pack:� racy Type of Cas Specifications <br /> M Public I:1 Other 0 Delta Depth of Grout Sea Type of Grout <br /> ' G Irrigation pprox. Depth 0 tEastern Surface Seat Installed by <br /> Repair Work Done Type of Pump.. 1 H.P. State Woe no �J <br /> Well Destru O Will Diameter 4 I Sealing Material i Depth <br /> Depth —Filler PA eridl L Depth <br /> T PE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION L7 DESTRUCTION M iNo•septic system permitted if public sewer is <br /> f ,: P evailabl6 within 200 feet.) <br /> I; Installation will serve: Residence� Cvmmerciai ther <br /> 1 Number of living units: Number of bedrooms O <br /> 1 Character of soil to a depth of 3 feet: < <br /> .-- � Water table depth -fy <br /> SEPTIC TANK. �� Type/Mfg �aNcc�'� Capacity No. Compartments <br /> I PKG, TREATMENT,PLT. ❑ I# �,. Method of D) osal f <br /> i Distance to nearest: Well t Foundation - 1 Property Line <br /> LEACHING LINE ® No. & Length of lines _`5 CJ' N Tai length/size , <br /> FILTER BED ❑ Distance to nearest: k Foundation -/n Property Line <br /> i <br /> SEEPAGE PITS 11 Depth ZSize' Number <br /> f <br /> ` SUMPS Ll Distance to nearest: ��._� Foundation ,.��Z Property Line <br /> x \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, anc--C' <br /> rules and regulations of the San Joaquin County , <br /> Home owner or licensed agent's signature cenifies 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 subcontracting signature <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." t <br /> The applicant must ejol for all re ed inspections. Complete drawing_on_rova se side, <br /> xSigned X Title: Date: <br /> FOR USE ONLY p <br /> r . Application Accepted by r+%21 N kl ii +f1 Data ` Area <br /> Pit or Grout Inspection by Date Final tnspection by Date <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 O BOX 2009, STOCKTON, CA 95201 <br /> FEEOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO GASH <br /> . <br /> EH 1321 tlIEV.r/K5i <br /> E .26 �LJ CJ (jJ� — <br /> H:1 <br />