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I <br /> I� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 i <br /> I� P 0 BOX 2009, STOCKTON, CA 95201 <br /> iM <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> �F <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 Publi{cHeeaaalth /Services. <br /> Job Address _ ` r r " City N Lot Size/Acreage <br /> Owner's Name J .r , Y Addre s r � t, Phone <br /> e _ �^ <br /> Contractor. I f ess r /t/ License N_o. a 5 � Phone <br /> 5/2 io2v_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION'Cl' SYLMIRIEPAIR ❑ OTHER ❑ Monitoring WellDISTANCE TO NEAREST: SEPTICTANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNbATiON AGRICULTURE OTHER WELL ' PITS/SUMPSINTENDED USI= II TYPE OF WELL PROBLEM AREA CONON SPECIFICATIONS <br /> C7 Industrial', ❑ Open Bottom ❑ Mantec4) De <br /> Well Excavation Dia. of Well Casing <br /> y <br /> fl Domestic/Private ❑ Gravel Pack Q, 'Tracy f Casing_ ' Specifications { <br /> I'1 Public y 1_I Other n Deltaof Grout Seal .� Type of Grout <br /> I ! Irrigation ' —.Approx. Depth I i Eastern Seal Installed11yRe air Work Done LJ T p p i, ype of Pum State Work Done <br /> Well bestruction - ❑ ;Well Sealing 4terial A Depth <br /> Depth ° biller Material i Depth r ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is i <br /> E l available within 200 feet.) <br /> Installation will serve: Residence i Commercial the Y <br /> Number of living units:I� Number of bedroi�nls <br /> v 3 Ch_aracterfof soll'to a depth of 3 feet: Water table depth <br /> SEPTIC'*TA6-..� O Type/Mfg Capacity0 No. Compartments <br /> PKG. TREATMENT PLT,❑ t Method of bispospk , <br /> Distance to nearest: Well " Foundation I Property Line Lir r <br /> r. ! <br /> `1 <br /> LEACHING LINE 0 No. & Length of lines Z&IINE To I length/size <br /> FILTER BED O Distance to nearest: Wall <br /> Foundation Property Lina , <br /> SEEPAGE'PIT.S I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Pr <br /> operty Line <br /> I DISPOSAL PONDS 0 ' <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 /> I <br /> rubs and regulations of the San Joaquin County laI <br /> Horne 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 i <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 1 <br /> certifies the following: "I certify that in the performance of the work for which this permit is Issued,I @hall employ persons subject to workman's compensa- <br /> tion Iowa of California.-, <br /> The applicant 71 call for all r ed inspections. Complete drawing an r erse side <br /> Signed Title: LKS Date: <br /> FOR DEPA MENT USE ONLY <br /> I <br /> Application Accepted by ,I10AV /A:S_ <br /> Dots Area <br /> M s <br /> t /1,00or <br /> r <br /> Pit or Grout Inspection by' Date Final Inspection by A Data I <br /> Additional Comments: II <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 9 445 N San I� Joaquin ox 2009, Stkn, GA 95201 <br /> IF EE 0 AMOUNT DUE AMOUNT REMITTED K LVED BY 9ATE PERMIT'N0. <br /> . EH 1 <br /> 324 IREV.1/M tlY <br /> EH 14.20 f/� • / � -I <br /> J <br />