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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> k ENVIRONMENTAL HEALTH DIVISION Q130 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 t <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)- <br /> Application is hereby made to San4Joaquin County for a permit to construct and/or install the work"herein described. This <br /> application is trade in compli ce vith San Joaquin County Or finance No. 549 and 862 and the Rules and Regulations of San <br /> Joaquin County Public Health vices. <br /> a <br /> Job Address V * City Lot Size/Acreage <br /> Owner's Name Address, i r Phone <br /> --Gontrac.tor _ . gddres.s:: - �s. / / �_ <br /> License-No. _Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well 0 <br /> PUMP INSTALLATIONSYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICUL E WELL F OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS <br /> D industrial ❑ Open Bottom ❑ Ma c pia. of Well Excavation Dia. of Well:Casing <br /> f7 <br /> Domestic/Private ❑ Grave! Pack racy Type of Casing_ Specifications <br /> I i'1 Public 1-1 Dther f� Delta Depth of Grout Seal Type of Grout i <br /> I i Irrigation _Approx. D h I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of P H.P. State Work Done__ <br /> `Well Destruction 0 Well ' meter Sealing terial & Depth _ <br /> Filler Material & Depth' Wf y <br /> Depth F <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION-1' REPAIR/ADDITION I I DESTRU,CT1ON I INo ptic syst permitted if public sewer is r- <br /> P11 - available wk n leq{.►_ <br /> Installation will serve: Residence Commercial Other r LLL!!!/ '• r q'jJ/i�'i <br /> Number of living units; Number of bedrooms Y L +.; `C <br /> Int J IN <br /> Character of soil to a depth_of 3 feet: ' r ! f Water table r <br /> SEPTIC TANK 0 Tyyppe%Mfg � a Capacity No. Compartments <br /> .. . <br /> PKG. TREATMENT PLT. ❑ Method of Dispo I _ <br /> Distance to nearest:-.- _ Well Foundation Property Line-+ r <br /> Of <br /> LEACHING LINE ❑ Na:& Length of lines of 1 ength/s a <br /> FILTER BED ❑ Distance to nearest: well Foundation Property Line F__ <br /> SEEPAGE PITS 11 <br /> Dep Size tuber i <br /> SUMPS ll Distance to�e"st:' Mail 0.kA,;ndafloeZ: Property Line ' <br /> t DISPOSAL PONDS p <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 t <br /> rules and regulations of the San Joaquin county '° j��:. '+t � y <br /> Home owner or licensed agent's signature certifies the following:`,l certify that in the performance of the work for which this permit'is issued, I shall not <br /> -ecompensation laws of California." Contractor's hiring of sub-contracting signature <br /> employ any person in such manner.as to become subject to workman' 4 <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 Flust{call toroe, <br /> utrd i pections. Complete drawing on reverse sid. <br /> SignedTitle: _ 1 _ Date: Q <br /> OR DEPARTMENT USE ONLY, <br /> lication Accepted by l " .3 d ^ Z <br /> Date Area 1 <br /> Pit r Grout Inspection by Date Final Inspection b' 4f Date, <br /> Additional Comments; ` f <br /> i - ++ <br /> Applicant _ Return all evpi�es to: San Joaquin County Public Health Services � <br /> Environmental Health Permit/Services ,1 t' s ,< ,• <br /> 445-N San Joaquin, P. 0 Box 2009, Stkn,,CA 95201 ,, <br /> NEE AMOUNT DUE AMOUNT REMITTED IA RECEIVED BY DAT PERMIT'NO. P <br /> INFO � v CASH '] <br /> . EH 77.3,IREV.'oinsi v(! / f 3 1-3�yZ <br /> EH 71•2E r ( t�� <br />