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5 "LICATION <br /> 't;� s R <br /> /AQUIN COUNTY PUBLIC HEALTH hYS <br /> AA <br /> � � ENVIRONMENTAL HEALTH DIVISI 45 N SAN dOA UIN PHONE (209)4 :` Q <br /> Y+ti <br />. �GD��ZS �� P O BOX 2009, STOCSTON, CA 9�5��# �S <br /> r. <br /> ZO rt1�0 G� if PERMIT EXPIRES 1 YEAR FROM DAT I9 g <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wor scribed. <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and of San <br /> Joaquin County Public Health Services. <br /> Job Address �+ city_ Lot Size/Acreage �_ <br /> Owner's Name - + <br /> d <br /> � Address � '� J 'i✓ Phone q g <br /> .�.� :& I <br /> Contractor Ydress License N07 e J Phone <br /> TYPE OF WELL/PUMP: NEW W L ❑ WELL REPLACEMENT 171 DESTRUCTION Cl Out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ Monitoring Well r <br /> DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLD, PROP. LINE <br /> A CUFOUNDATION <br /> WELL OTHER WELL Y PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS I <br /> Cl Industrial ❑ Open Bottom— ❑ Man c Dia. of Well Excavation Casing r�; - <br /> f7 <br /> Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing_ clTcanons I A r <br /> I'1 Public f:I 911ger� Delta Depth of Grout Seal rout <br /> I I Inigatian ppiox. Depth, 1 EasternSur(ace Seal Installed by_ ADD 11 K 1024 <br /> Repair Work Done U Type of Pumps f '�N .� Statecyk.D,q[18 <br /> Well Destruction ❑ Well Diameter u '� sling Material 6 Depth RiV JUH 5 `( <br /> Depth Filler+Material b Depth 10t, <br /> TYPE OF SEPTIC_WPRK: -NEW INSTALLATION III REPAIRJADDIT1104I I DESTRUCTION I I lNo7seplic system permitted if public sewer is <br /> available within 2011 feet.I <br /> §' Installation will serve: Residence Commercial tl+er c <br /> Number of living units: Number of bedroo <br /> Character of soil to a depth of 3 feet:' Wate�table depth <br /> '• j <br /> SEPTIC TANK. ❑ Type/Mig Capacity No. Cbmprtments <br /> PKG. TREATMENT PLT.❑ f Method of Disoosio <br /> Distance to nearest: Well 47 Foundation Property Line <br /> i <br /> LEACHING LINE ' Cl No. III Length of lines Jotal lengt IiiZe <br /> FILTER BED (i Distance to nearest: Well Foundation Pr <br /> a aperty eI�P WA-11 151 <br /> it <br /> SEEPAGE PITS 11 Depth SizeF N er <br /> _ SUMPS Ll Distance to nearest: Well Foundation �,� Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I R614lprepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of 16 San Joaquin County „r- <br /> . Home owner or licensed agent's signature certifies tha_fgllowing: "I certjty_that in the perforrnance of the work-1 or which this permit isjissued, I shall not <br /> employ any person in such)manneras 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 a p icant st call for, a uired'rnspe' tons. Complete drawing on reverse side. <br /> E <br /> j <br /> Signed y ? � ! }-� Title: �L��—L l�`'-I � Date: <br /> (� FOR EPARTMENT USE ONLY <br /> J <br /> Appficetion Accepted by t I` `1 Date res <br /> ms's,. r-,•- � -1 <br /> GroI 7Ft inayl <br /> inspection by Inspection by pate c <br /> Data <br /> Comments: <br /> sl <br /> r r <br /> "-kv ij\,J i t) <br /> Applicant - Returnl ail copies to: San Joaquin County Public Health"Services <br /> Environmental Health Permit vi <br /> Seices <br /> ( 445 N San Joaquin, P O Box009, Stkn, CA 95201 <br /> FEE <br /> iNF i AMOIj T DtJE �,/ AINOU T REMITTEDr�-`CKRECEIVED BY I DATE PERMIT'NO. <br /> . EH 13-24 IREv.i i <br /> EH 1425 1 ` r �L✓ t� <br /> � I <br />