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APPLICATION _ m <br /> r <br /> SAN JOAQUIN COUNTY'PUBLIC HEALTH SERVICES <br /> ENVIRONMENTALHEALTH DIVISION <br /> f 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> f <br /> d PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> III 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 c1�Hance with San Joaquin County Ordinance 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> Lot Size/Acreage �•/ n�ii L- 0 <br /> { Job Address City <br /> Phone <br /> - <br /> 1 _ <br /> Owner's"t Name- �I Address <br /> F' Contractor Address License N Phone Z <br /> TYPE OF WELL/PUMP: �:`�'NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well ❑ <br /> r SYSTEM REPAIR C7 OTHER O Monitoring Well <br /> I: <br /> PUMP INSTALLATION ❑ <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK WEA LINES DISPOSAL,FLD. PROP. LINE <br /> + { FOUNDATION A RICULT E WELL OTHER WELL v PITS/SUMPS ,r � <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> I-] Industrial 0 Open Bottom 0 Mante Dia. of Well Excavation _ 9 r <br /> i ' Specifications <br /> C:1 Domestic/Private ❑1 Gravel Pack ❑ Tr y Type of Casing_. <br /> I'1 Public (-1 Other vita Depth of Grout Seal Type of Grout <br /> I 1 IrriOation M Approx. Oepth , I Eastern_ ,�, !urface-SsdI,Installed by <br /> Repair Work Done 0 Type f Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter <br /> J Se ng Material & Depth <br /> Depth Fill Material,A Depth f „, <br /> " TYPE OF SEPTIC WORK: .NEW IN LATION REPAIR/A IO I OLEoq ` STR CTI I 1 �i�o septic system permined it public sewer is'` 0 <br /> I,- ^ F avai his within 200 feet.) <br /> Installation will serve: Residence Commercial Qther f f t <br /> a ! Number of bedrooms <br /> Number of living units: �' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> G <br /> SEPTIC TANK ❑ Type/Mfg & Caparity No. Compartments <br /> PKG. TREATMENT PLT. o Method of Dispo I•r <br /> f istance to nearest: Welt' Foundation _d_�C! Property Line + <br /> Y + <br /> ' LEACHING LINE ❑I No. & Length of lines 11) To I length/size 2 t. <br /> i FILTER BED C 1 ; Distance to nearest: Well Foundation Property Line 3 <br /> t <br /> SEEPAGE PITS II Depth Df- Size I umber_ - — <br /> P - SUMPS LA,i Distance'to_nearest. Well oundation Property Line ' <br /> DISPOSAL PONDS ❑;' r <br /> I hereby certify that I have prepared this application and that the.,wwork will be done in accordance with San Joaquin'county ordinances, state laws, and <br /> rules and regulations of the an Joaquin County <br /> Home owner or licensed agent's signature certifies the following: '9 cartify 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 subcontracting signature <br /> certifies the following: "Icertify that in the performance of the work fof which this permit is issued, I shall employ persons subject to workman's compensa- <br /> I Non laws of California." <br /> The applicant m tail for Iall1fdoired ins tions. Complete drawing on reverse side. <br /> Signed Title: m Date: - <br /> A DEPARTMENT USE ONLY,` <br /> Application Accepted byx ' T Date Area - <br /> Pit orGroutInspection by I b Date Final Inspection by {Ddte s O Y <br /> Additional Comments: 5' <br /> Applicant - Returnallcopies to: San Joaquin County Public Health Services . I <br /> a I Environmental Health' ermit/Services - <br /> I 445 N San Joaqu , ox 2009, Stkn, CA 95201` <br /> d } <br /> AMOVNT DUE AMOUNT REMITTED C"-!.--"- RECEIVED BY DATE yW PERMIT'NO• <br /> ! FEE ":1 3 <br /> INFO _. <br /> ` Eli 13.24(REV.+/x Sl W. <br /> r EH 14.26 `III 111 <br />