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t <br /> 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 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRO DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to Baia Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.l �r <br /> Job Address Z.51: 14� D�L Y An_+ City Lot Size/Acreage <br /> Owner's Name Address .S$' d�tO Phone 6 <br /> Contractor ,� Address e2.) �. , �License No.�l ----Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT l7 DESTRUCTION ❑ Out of Service well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL T <br /> CONSTRUCTION SPECIFICATIONS <br /> F] Industrial CD Open Bottom nteca r Well Excavation Dia- of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack cy Type of Casr Specifications <br /> l'I Public (.1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation �.Approx. Depth I I Eastern Surface Sedl Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done V <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIN !No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms R G <br /> Character of soil to a depth of 3 feet: Water table depth C <br /> SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total longth/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE. PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 <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 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." <br /> The applicant mu call for all require Inspections. Complete drawing on reverse side 1 <br /> Signed Title: C/ -�/ Date: 1 <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <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 /> IFEEO AMOUNT DUE AMOUNT REMITTED C K Al RECEIVED By 1 DATE PERMIT'NO. <br /> EH t1241REV../ny 1 1 �` L <br /> EH 1420 FN/ `T l <br />