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F+ 2 APPLICATION � ' <br /> F' <br /> r r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p <br /> ENVIRONMENTAL HEALTH DIVISION � p <br /> 445 N SAN JOAQUIN; PHONE (209)468-3420 ti <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F (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 <br /> � <br /> ; Joaquin County Public Health Services. <br /> i EEE r <br /> Ad � <br /> dress ,L��Z S �!►^� City Lot Size/Acreage <br /> ��� / y 2 a 1 IS Phone <br /> tC <br /> er's Name l Y Address _.t,., 1, <br /> [' ractors �� __Address License fro. Phone <br /> 1E OF \NELL/PUMP_I� NEW WELL 0 WELL REPLACEMENT F1 DESTRUCTION 0 Out of Service Well ❑ <br /> EEE /-PUMP INSTALLATION, SYSTEM AIR 12 OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRI LTURE LL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. bl`Aell Casing <br /> M Domestic/Private 0 Gravel Pack ❑_T cy Type Casing Specifications <br /> r. M Public 1-1 Other 11 Delt Depth of ut Seal Type of Grout <br /> I I Irrigation _Approx. Depth, stein Surface Seal Ins ed by -- <br /> Repair Work Done 0 ; Type of Pump H.P. tate Work Done — <br /> r Well Destruction ' ❑ Well Diameter Sealing Material i Depth <br /> r <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRIADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is <br /> { •. � � � available within 200 feet.) n „ <br /> Installation Will serve: Residence_ Commercial _ Other�} vl QA <br /> Number of living units: 4 Number:of,bedrooms <br /> Character of $oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ?X,Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT Oft WCI ! Method of Disposal <br /> Distance to nearest: �Welf � oundation_i� Propeny line <br /> LEACHING LINE No. & Length'ol lines Total length/size I <br /> FILTER BED ❑ Distaride to nearest; Well ,Foundation Property Line ra <br /> SEEPAGE PITS 11 Depth `- Size Number <br /> 1 SUMPS Ll Distance,to nearesu Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this applicatign and that the work wilt be d$ne 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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractors hiring or sub-contracting signature <br /> wing: "I certify that in the performance of the work fpr which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic ust c r all required inspection Compt to drawing on reverse side. <br /> r 7 <br /> Signed Title: O�sJ}-� Date: / J <br /> FA D LY <br /> 2 <br /> r Application Accepted by Date 14. Area <br /> �--r <br /> FPit or Grout Inspection by Date—,Final Inspection by ff4.111A MD. Date <br /> Additional Comments: <br /> F_ <br /> ' Appl_icant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Lox 2009,. Stkn, CA 95201 <br /> aZZ INFO <br /> AMOUNT DUE AMOUNT REMITTED CK ' ECEIVED BY D TE PERMIT'NO. <br /> E / <br /> =: EH 17.24 IREv,r/M c <br /> �D � <br /> 1 EH 14.25 `! J <br />