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k <br /> �I APPLICATION <br /> SAN JOAQUIN (COUNTY PUBLIC <br /> ' HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOg:12009, STOCKTON, CA 95201 <br /> PERMIT R MES 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 Joaquid County Ordinance No. 50 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> .lob Address e%r"' City Lot Size/Acreage <br /> )( i <br /> f /Owner's Name + t r Address t a-r t.( Phone <br /> )(ContractorAddr 1 <br /> ass � <br /> License No. <br /> Phone m <br /> TYPE OF WELL/PUMP: NEW WELL ❑ I. WELL REPLACEMENT Fl DESTRUCTION ❑ Out of service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r w� <br /> ❑ industrial ❑ Open Bottom ❑ Manteca: Dia. of Well Excavation Dia. of Well Casing V <br /> CI Domestic/Private ❑ Gravel Pack C1 Tr Type of Casing_ Specifications_.._. <br /> Fl Public f7 Other Fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I I Eastern ii Surface Seal Installed by <br /> Repair Work Done U Type of Pump HP• State Work Dane - <br /> Well Destruction , ❑ J Wel!"Diameter, - Sealing Material & Depth <br /> ' Depth n Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIADDITtON I I DESTRUCTIOINo septic system permitted if public sewer is <br /> vailable within 200 le�t.l <br /> Installation will serve: Residence T.. Commercial__ tither �� d f/l <br /> Number of living units: Number of bedrooms 0 1 ' <br /> Character of soil to a depth of 3 feet: 11 <br /> SEPTIC TANK ❑ Type/Mfg 11 Water table depth <br /> PKG. TREATMENT PLT. Cl Capacit <br /> Y No. Compartments <br /> Method of Disposal � <br /> Distance to nearest: Well Foundation Property Line <br /> Ili <br /> LEACHING LINE C1 !f�No $ Length of lines Total length/size <br /> FILTER BED n Distance?to nearest: Wail 1 Foundation Properly Lina <br /> SEEPAGE PITS 1 1 'Depth Size ! Number r <br /> SUMPS <br /> Ll Distance to nearest: - r <br /> Well ! Foundation I <br /> I� Property Line <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that f 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 followinj"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 work'men's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the w irk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." paras• <br /> The applicant must call f <br /> rop al squired inspections. Complete drawing on reverse side. ! <br /> 1[Signed X 11 <br /> Title bra If 'tet <br /> Date: <br /> FO CMPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date I Final Inspection by Date' _571 <br /> g Q_3 <br /> f � <br /> Additional Comments: I /`! w ( .. �• a <br /> .lj. <br /> Applicant - Return ail copies to: San Joaquin;County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> ii <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Y <br /> INFO CASH DATE PERMIT'NO. ► <br /> i <br /> . EH 13.24IAEV.rips! <br /> EH 14•Ie N7 <br />