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SAN JOAQUIN COUNTY PUBLIC <br /> EALTH SERVICES S' <br /> ENVIRONMENTAL HEALTH <br /> ON <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES I YEAR FROM DATE ISSUED RV.7 <br /> (Complete in Triplicate) <br /> Application is hereby madeto San Joe nce No. 5 <br /> quin County for a permit to construct and/or install the work herein described. Sans <br /> applicstion is made in compliance with San Joaquin County Ordina1+9 and 1862 and the Rules and Regula <br /> Joaquin County Public Health Services. <br /> /] � © of Size/Acreage <br /> Job Address 0 e <br /> Phone <br /> Address <br /> Owner's Name ►� k <br /> License No� Phon <br /> CT <br /> Contractor DESTRUCTION ❑ Out of Service Well <br /> TYPE OF WELLlPUM NEW WELL.❑ WELL`REPLACEMENT Monitoring Well E7 <br /> PUMP IN ELATION O <br /> YSTEM REPAIR ❑ OTHER ❑ <br /> SEWER L S DISPOSAL FLD. P P. LINE <br /> DISTANCE TO NEAREST: SEPTIC TAN I OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRIC TURF WELL <br /> INTENDED USE TYPE OF WELL P LE REA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom ❑ M ca Dia. of Well Excavation <br /> El Industrial _ - - — Specifications <br /> C7 racy Type of Casing <br /> [-1 PubliDomestic/Private ❑ Gravel Pack Depth of Grout Seal a of% Grout <br /> is Other pelta <br /> i'1 Public ` <br /> I I Irrigation —.Approx. Dept of Pump 1 I Eastern Surface Seal Installed by <br /> H.P. tale Work Done <br /> Repair Work Done L7 Type Sealing rial fl: D <br /> Well Destruction O Well Diameter r I <br /> I Depth Filler Mate <br /> IREPAIR/ADD I 1ESTRUCTION septic system permitted it public sewer is <br /> I TYPE OF SEPTIC WORK; NEW INSTALLATION ( I , -.8v`ailable within 200 feeLl = <br /> ,e <br /> Installation will serve: Residence— Commercial_ Otha " ... <br /> f. <br />� Number of living unite: Number of bedrooms� * Water table depth <br /> Character of soil to a depth of 3 feet: Capacity __ No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> x <br /> PKG. TREATMENT PLT. ❑ p�YY <br /> Distance to nPar6st: Well Foundation �— Pro Line <br /> / I e , <br /> Total lengthlsizer....,_ <br /> LEACHING LINE L) No. p• '` r9th of lines Foundation F Property Line — <br /> t <br /> FILTER BED n D sya,.�e to nearest: Well <br /> } <br /> Size Number' <br /> SEEPAGE PITS ' Depth Foundation Property Line <br /> SUMPS El Distance [o nearest: Well a <br /> DISPOSAL PON ❑ <br /> I hereby ce 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 a regulations of the San Joaquin county <br /> Ho 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 /> mploy any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub Contracting signature <br /> performance of the work for which this permit is issued,'I shall employ persons subject to workman's compensa- <br /> certilias the following: "I certify that in the <br /> tion laws of California." <br /> The applica st r u'red i tions. Com ate wing on r arse side. �] <br /> Title: <br /> Date: U <br /> Signed <br /> r R�IPTMENT USE ONLY* <br /> f i <br /> y Dates Z� Area <br /> Application Accept by .� �✓ ��` <br /> Pit or Grout Inspection by DateFinalInspection by Date <br /> , <br /> 1. <br /> Additional Comments: <br /> Applicant - Return all copies to: Environmentaln Joaquin oHealth unty upermit/Services <br /> blic Health vices <br /> 445 N San Joaquin, 'P O Box 2009, Stkn, CA,95201 <br /> y FEE AMOUNT DUE AMOUNT REMITTED Agµ - <br /> RECEIVED BY DATE PERMIT N0. <br /> I INFO _ <br /> . EH 1321 ISEV.r/n sr <br /> EH 1416 <br /> i ' <br />