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c 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 <br /> I' PERMIT EXPIRES 1 YEAR FROM DATE ISSN <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 trade in compliance with San Joaquin County Ordinance No. 549 and 862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. � 1 le Ccs <br /> dCity Lot Size/Acreage �/� <br /> Phon <br /> ob Address ' <br /> Owner's Name <br /> Address <br /> A� ddress !� License No. T Phorle <br /> Contracto � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Storing Well <br /> C Well D <br /> ;i PUMP INSTALLATION D SYSTEM REPAIR Q OTHER <br /> DISTANCE TO NEARS IC TANK SEWER LINES DISPO PROP' LINE <br /> FOUNDAT AGRICULTURE WELLOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom anteca <br /> of Well Excavation Dia. of Well Casing <br /> Specifications <br /> � <br /> ! C.l Domestic!Private ❑ Grave ❑ Tracy Type of ^ ' <br /> Depth of Grout Sea Type of Grout— <br /> I'] <br /> rout <br /> I'I Public ther fl Delta U <br /> Irrigation _.Approx, Depth I i Eastern Surface Seal Installed by <br /> ll Re ' ork Done U Type of Pump H.P. State Work bone_ <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i INo septic system permitted if ptiblic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <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. Ll <br /> Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 1,3 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> .1 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 <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 foItowin : "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 Cali ia." <br /> The applican st call for all re it in ctions omptete drawin70S48v6rse sideeSigned Title !.d- C."' `� -- Date: "!l <br /> F pFPARTMENT USE ONLY <br /> Application Accepted by DateArea <br /> Pit or Grout Inspection by Date Final Inspection by Date/ <br /> Additional Comments: ' <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO n (� <br /> . EH 13.241REV.1/8151 1 �+�+ i t { �/t I l q I <br /> EH 14.2E 111 <br />