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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, 'PHONE (209)468-3420 <br /> P O 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 j <br /> Joaquin County Public Health Services. I <br /> 30AL +�i ; Cit ,i <br /> .fob Address `s /y� ��f Lot Site/Acreage ¢ !i <br /> )(Owner's Name � t2 Address ` '"" °¢C Phone (� �°��J 6 S <br /> �( �+�4 / Address License No. Phone <br /> I -Gontractor <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT M DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM AIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK S ER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG CULTURE ELL OTHER WELL PITSISUMPS — <br /> INTENDED USE TYPE OF WELL AACTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom f Well Excavation � Dia. of Well Casing <br /> Cl Domestic/Private Cl Gravel Pack of Casing_ Specifications <br /> I'I Public I 1 Other h of Grout Seal Type of Grout <br /> I I Irrigation ._-_..Approx. Depth Ia Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Matert & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I. REPAIR/ADDITION VI DESTRUCTION l I lNo septic system permitted if public sewer is �} <br /> available within 200 feet.) /— •� �� <br /> Installation will serve: Re�s�p ` <br /> nce— Commercial Other [ctCG <br /> �dJC • ��` `�Y <br /> Number of living Unita: J_ Number of bedrooms �QO -A-1�wJRvoS �r'!'� � <br /> Character of soil to a depth of 3 feet: Water table depth T ...e <br /> SEPTIC TANK ❑ Type/Mfg 'l Capacity ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4dd ellx�w�f p �' -6—�ec Co,,- Method of Disposal <br /> Distance to nearest: Well Foundation p`c Property Line c <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance'to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt 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 must call for a I r quired inspections. Complete drawing on reverse side. <br /> I <br /> (Signed Title: ��` Date: <br /> FOR DEPARTMENT USE ONLY <br /> s^Appiication Accepted by • Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date LDS <br /> - I <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Servi <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> . EH 13-24(REV.I/x 51 <br /> EH 14-n Iy <br /> a 1 <br />