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APPLICATION <br /> SAN JOAQU TY PUBI{gl�T <br /> 1 t - TIBUC <br /> ' TAL HEALTH � �¢,;i„�S7ERVICFS <br /> Cf�l`�JOg(�LT 6; btJ� f� 445 N 'SFJOAAOQTUIN, PHONE (20 II.TISI®N <br /> E _ P O vB0% 2009, STOC%TON, �� q�, f <br /> C'.. 1. _.. as g <br /> ' = PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> r (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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job Address <br /> f City .� � Lot Size/Acreage <br /> Owner's Name �,C'�fJ l L Address �+ ��- Phone �« l <br /> t Ohl,rte� 7 <br /> Contractor Address License No. Phone ,S <br /> TYPE OF WELL/PU �/3P: NEW WELL C1 WELL REPLACE NT F1 DESTRUCTION C] Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑• ' OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE (��l <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ° <br /> f 7 Industrial ❑ Open AQ %fU—JnyWWWR � Dia., VWell Casing <br /> f:l Domestic/Private - CI Gravel Pack � rISIOIV{ R• 5 <br /> iI PuG <br /> blic ' - pecifications <br /> .] Other �� Type-"of Grout`' <br /> I I Irrigation :�Approx. Depth d-by i y" <br /> Repair Work Done L7 t' <br /> ype,of Pump H.P. ; <br /> --� State Work 1Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depths ' '"�'^� ---- - —Filler_Meteriai_i pepth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITIO 111,11I DESTRUCTION I I INo'septic syster"r0ermitted if pJ"we, ,s- <br /> Number <br /> is- <br /> available wiihin 200 feet., <br /> Installation will serve: Residence_.- Commercial_ Other . �` . „ a /,1 <br /> of living units: Number of bedrooms Character of soil to a depth of,i feet: Water table de <br /> SEPTIC TANK. ❑ Type/Mfg fTb ----»� depth <br /> C� acity •�---1--s No. Compartments <br /> PKG. TREATMENT PLT. C7 r <br /> kf .<_._ Method of Disposal <br /> Distance to nearest: Well FoundationProperty Lin <br /> d ! <br /> LEACHING LINE PQ No. & Lendth of lines Total length/site cr <br /> FILTER BED C] Distance to nearest: Well _ <br /> Foundation Property Line <br /> SEEPAGE PITS xU Depth Sire <br /> Number <br /> SUMPS -------�---- - <br /> Ll] Distance to nearest: Well Foundation 'I "- 1 ` <br /> DISPOSAL PONDS ❑ �a/ 4�� Property Li <br /> � � 1 <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 /> 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 shelf 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 all requ' ins tions. Complete drawing on reverse side. <br /> Signed ,r <br /> Title: <br /> Data: ..� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ _ _ pate `-ID_9-3 Area O Z r•J4q . <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date 3 <br /> Additional Comments: i <br /> IS <br /> Applicant - Return all copies to: San Joaquin CountyyP lic Health—Services ; <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 K((/L� <br /> FEE AMOUNT DUEAMOUN REMITTEp <br /> INFO Cx RECEIVED BY O TE PERMIT'NO. <br /> « EN 1 -24IAEV,t/r Sl <br /> EN 144.7e <br />