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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t SNVIRONIMTAL HEALTH DIVISION <br /> 445 -N SAN JOAQUIN, PHONE (209)46$-•3420 <br /> '] P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES M <br /> - DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby Iaada,t0 8= Joaquin county for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Elan Joaquin County Ordinance No. 549 and 1862 and the Mules and Regulations of San <br /> Joaquin County Public Health Servidee. <br /> Job Addrssi r� t r `� City tat Elise/Acreage i, �- <br /> 1 I <br /> Owner's Mame � � Address <br /> ._,_. Phone <br /> Conlrattor __ � Address '7 License Ns ��/ Phone �� t <br />( TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Seraioe Irel1 0 <br /> I PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O Monitoring Vell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATIONS IAGRICULTUREWELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom. ❑ Mameca Dia. of Wall Excavation Dia. of WeII Casing <br /> t t1 Domestic/Private 0 Gravel Pacic7 ❑ Tracy Type of Casing_ Specifications <br /> Il Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout .. <br /> I I Irrigation —.Approx.. Ipth I I Eastern Surface Seal Installed by �. <br /> Repan Work Done 0 Type of Pump f H.P. State Work Done <br /> Wall Destruction 0 We"Oismater ;' ling faterial i -Depth. <br /> .. Depth tiller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADOITlON „DESTRUCTION i I IN-septic systemI <br /> permitted if public sewer is <br /> available within m0 feet.) I <br /> InslaGafion will serve: Residence— Commercial�Othar y F <br /> Number of living units: Number of bedrooms t — a <br /> Character of soil to a depth of 3 fast: r Water table depth <br /> 1610 <br /> SEPTIC TANK. Er Type/Mig Capacity—/6 —T No. Compartments f <br /> PKG.TREATMENT PLT.0 .1. <br /> r Method of Disposal <br /> Distance to nearest: WON Foundatfp n prorty Line <br /> t <br /> } E4. w <br />' LEACHING LINE No. &Lsnptti df•lines r Total length/size—_60-1 �l <br /> FILTER BED W Distance I*'4n 4t: Wew1__.Z2_6W Foundation..a Property Line <br /> SEEPAGE PITS I W!Deptha� l"t s; r' I <br /> Number <br /> SUMPS L! Olatanca to nearest: We 111 —0f ` Foundation /.� Property Line a <br /> DISPOSAL PONDS 0— 4 '" <br /> hereby certify that I have prepared this 20611cation and that the work will be done in accordance with San Joaquin county ordinances,state taws,and <br /> rules and regulations of the San Joaquin 641oty ' <br /> Home owner or licensed agent's signature berfifies the following:"I-certify that In the'parlormance of the work for which this permit is issued,I shall not <br /> ampj <br /> kyy any person in such manner ale to-bacoene subject to workmen'$compensation laws of Ci[ifornii."Contractor's hiring or sub-contracting signature <br /> certifies the foEowing:"I COMM that in the Pitiormance of the work for which th <br /> tion laws of Csflfamie. r.! ii'patmit is issued,!shelf employ parsons subject to workman's wmpensa- F <br /> The apple can or All uk w Y <br /> mspectiars. Complete drawing on rover"side. <br /> Signed Title: L � Date: y <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by. <br /> Data Area <br /> �t 4 Pit or Grout lnspaction by Q n 11 lA I <br /> ate FI <br /> �i nspectloti <br /> is ?ti'/�►/nf/1 'Y/J'�.� <br /> Additional Comment*!* . . <br /> Appiicslnt - Return all Copies to: Elan Joaquin County Public Health Services r <br /> Environmental Health Permit/Services. <br /> 145 H San Joaquin,•P 0 Box 2009, Stkn, QA 95201 <br /> IFEE AMOUNT DUE AMOUNT REMITTED ECEIVE oY DTE PE�RjMR'IVOA. <br /> S •11H 13-2X4 fN1a-nIfFN.I/its) II ' 010 ��v <br /> i t <br />