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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> a x ENVIRONMENTAL HEALTH DIVISION <br /> 445 N�QQSAN JOAQUIN, PHON �?��� �420 <br /> UNTY-PUBLIC HEALTH SERVICES I <br /> SAN JoAQUIN COUNTY-PUBLIC HE S�R�'I�09' STOCgT i ENVIRICINMENTAL HEALTH DIVISION <br /> ENVII'^NMENTALHEAL%T NOPIRES 1 YEAR FROM DA E" ISSU PERMIT PERIAMComplete in TriplieMt :k :- `L <br /> ` ' <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 <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address ,. IIQ <br /> Owner's Name <br /> �� 54911 III Address + Phone <br /> License No, Phone <br /> 46 <br /> Contractor Address- <br /> W7 PService Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El " DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ <br /> DIST? O"NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE.OF W ROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial CT-0 pen Bottom ❑ Man Dia. <br /> of Well Excavation <br /> Dia. of Well Casing <br /> CHEAL ZME[ViCBS f Casing_ Specifications <br /> �-'-" Depth of Gro7nstat—led:� <br /> al Type of Grout <br /> I.1 Public ENVIRONMEf 'fl�h.'HEALTH DIftft <br /> I I Irrigation yy. f pprooxx. De th I I Eastern Surface SealRepair Work �`eAkX. JQLpN.P. te oneSealing Material & h <br /> Well Destruction's ❑ Well Diameter N <br /> r Depth kller;Naterial & Depth <br /> TYPE OF SEPTiC WORK: NEW INSTALLATIONREPAIRIADDITION I i DESTRUCTION I (No septic <br /> cystithin m perm <br /> titled if public sewer is IS <br /> Installation will serve: Res' nce Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of axil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ TypelMfg Capacity Na. Compartments ; <br /> Method of r osal l <br /> PKG. TREATMENT PLT, Cl <br /> Distance to nearest: Well Foundation Property Line <br /> s [ 30 S Q <br /> LEACHING LINE L1 No. & Length of lines � T tel length/size <br /> FILTER BED; ❑ Distance to nearest:: ",,Well F ud Property Line <br /> SEEPAGE PITS 11 Depth Siie 33 Rumber <br /> SUMPS 0 Distance to nearest: Well�-T—Foundation Property Line 142 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I. rules and regulations of the San Joaquin County <br /> i Home owner or licensed agent's signature•tenifies 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 suchma r as become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followin rty tha a performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> tion laws of n a." <br /> The plicant must call for all r wired ins tans. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date '7110 Area a< <br /> u 'r- 4/A d� *'414 Date 1� <br /> Pit or Grout Inspection by ��`' Date Final Inspectitsn by <br /> j5� pliprf � .�a fang$. <br /> Additional Comments: // yy�� rn p <br /> Applicant - ReWft 1 cop*eA5: en Joaquin >"ry ab/lio e ervice <br /> f Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, 'CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED41U) I <br /> RECEIVED 9Y D TE PERMIT"N0. <br /> INFO EK 13-21 rR£V.ti wSI1If711 D <br /> EK 14.25 <br />