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APPLICATION FOR PERMIT <br /> r <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 EXPIRES 1 YEAR FROM .DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> JobAddress �l • l���� e CityLot Size/Acreage <br /> Owner's Name �L I �V C� PV)21 Address _S- © k W - U Q3DN t.1 C- 'Phone <br /> Contractor OS Address p��ay�lCe1Y �1)� License No. __'2_S_Q5$A3__Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTIONS Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .r <br /> INTENDED USE TYPE OF WELLOf9LEM.ARE CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ anteca Dia. of Well Excavation 1 Dia. of Well Casing <br /> N Domestic/Private V Gravel Pack L7 Tracy Type of Casing Specifications <br /> V) Public Cl Other el Depth of Grout Seal �(�� Type of Grout <br /> I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by S61PAQUil3— <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public 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 1 ' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> LEACHING LINE C1 -No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well +Foundation Y Property Line <br /> SEEPAGE PITS 11 Depth Sire Number I <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> 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, 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." - - F <br /> The applicant must call for all required inspections. Complete drawing on reverse side, <br /> Signed Y Title: 2N2&crla,_* _ Date: <br /> + FOR DEPARTMENT USE ONLY o, r <br /> Application.Accepted by Date <br /> Pito Grout I spection by Date r_•gip Final Inspection by 1 Date J <br /> Additional Comments: e ub Mr �-%} Po. C f. ' 2 P) <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 K 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMI7'NO. <br /> . EH 43,24 1REV.1/R 51 iuW r O� ��`� L(I I,5,`1L 41B <br /> EH 14.20 <br />