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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT - RES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ` Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein de abed. <br /> application is made in atm@liana with San Joaquin County Ordinance No. 549 a d 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Service a <br /> / City Lot Size/Acreage <br /> Job Address _�—.�p f .. � n <br /> C l <br /> Address <br /> Phone_ <br /> Owner's Name __. �p( <br /> Contractor Address <br /> Q J icense No. 0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R LACEMENT`O. DESTRUCTION-❑ Out..of Service WI-11C <br /> :� monitoring Well <br /> PAIA,0A -i OTHER ElPUMP INSTALLATION ❑ S TEM RE <br /> DISPOSALFLO, ,PROP.4LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK WEA LI PITS/SUMPS <br /> _ <br /> FOUNTIO <br /> DAN, A ICU URE WELL OTA�R.WELL <br /> INTENDED USE �y PE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑;Open-Bottom ❑ Mont a is. of Well Excavation <br /> r T Type of Casing Specifications <br /> ❑ Domestic/Private Cl'Grave!'Pack� ❑ T cy 1 Type of Grout <br /> I'I Public ❑ 0ther �( Ila Depth of GrouteSeal. t I <br /> I I Irrigation 117t�.Approx. Depth` i 1 Elastern Surface Saul,'nstelled by <br /> 1 Repair Work Done ❑ Tyise-of-Pump a H P SIe[h��Jork dine_ <br /> 1 Seall Material i Depttt,n <br /> Wel! Destruction ❑ Wel! Diameter Piller, Lariat i Depth �� �• <br /> Depth <br /> h TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITI I I DESTRUCTION-I Irafvailablerwtt sl 200 frnllted it public sewer is <br /> ! Installation will serve: Residence Commercial � Other <br /> r <br /> Number of kvlrlg units: __ NUTDer Of bedrOOmi — ' <br /> Character of wit to adapth o13 feel: -1 /t 11Y�� Water able,depth <br /> I t o4 r CsPacitYtmPartrnents <br /> { SEPTIC TANK ❑ Type/Mfg - "/ <br /> r ,I k ' ap <br /> �v:-1 � V t` ,1, /,gym thud of Dispose <br /> �PKG.:TREATMENfi PCT. ❑ ! <br /> Distant`to nearest: Well ! Foundation Property line <br /> LEACHING LINE` IJ ❑ No. i L6ngth of lines! <br /> s otat length/size <br /> 1 FILTER SED ❑ Distance'to nearest: !-Well r /Foun�tior �_ Property Line <br /> I .) p� <br /> SEEPAGE PITS I I Depth ! Siie !'IO/�ba-r 1 <br /> SUMPS Ll Distance to nee sat: Well_,Lj Foun6lon V.5RC1 Property tine <br /> k DISPOSAL PONDS ❑ ^/ /' �' sI <br /> I hereby certify that I hews props red this application and that the,work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rubs and regulations of the Sen Joaquin County - t 7? .. <br /> Home owner or licensed agent's signature certifies the f6howing: "I certify that in the performance of the work for which this permit is issued. 1 shall m <br /> I employ any person in each manner as to become subject Po workmen's compensation laws of California."Contractoes hiring or sub contracting signator <br /> certifies the following: "I unify that in the performance of the woi,k for which this permit is issued, I shall employ persons subject to workman's compens <br /> tion laws of California." I <br /> The applic must e sit quer 'inspecuons. Complete drawing on reverse side. 2_ �� <br /> r' a 'lt/ r"TL. t /1 <br /> Signed <br /> Ta (I <br /> Title: _ i " � oats: <br /> ' FOR DEPARTMENT Uof SE ONLY <br /> _ / ^. Date Area <br /> Application Accepted by �jy� <br /> Pit or Grout Inspection by <br /> Date Final Impaction by��y"7�'-�--- Oete l <br /> , <br /> Additional Comments: <br /> Applicant - Return all copies tot Ban Joaquin County Public Health <br /> If Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> ! NFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BV DATE PERMITNO. <br /> !, ! EH 1Szr IRLV. <br />