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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES = ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> FF 1P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .! (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 /> Joaquin County Public Health Services. <br /> Job Address 0 Gity Lot Size/Acreage <br /> .t=V nr�- d ' <br /> Owner's Name Address Phonet!i3_4_TzL <br /> Contractor Addresste2:CT_: License No. 42gV16 Phone 0100 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well ❑ i <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> * Industrial ❑ Ope ttom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ravel Pack racy Type of Casing._ Specifications <br /> f'1 Pu is Other ' ❑ Delta Depth of Grout Seal Type of Grout <br /> rr1-u-uon Approx. Oepth astern Surfs. eal Installed by <br /> Repair Work Done Typo of Pump Vt H.P. State Work Don r <br /> Well Destruction ❑ Well Diameter Sealing Material k Depth 1 <br /> -)oDepth 1 Filler Material d Depth �u {� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is Vv <br /> ..i available within 200 feet.) <br /> Installation w4l serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: WaterPbA "ded <br /> SEPTIC TANK ❑ T ` <br /> ype/Mfg Capacity No. C <br /> ENT <br /> PKG. TREATMENT PLT, Gl MethIVED <br /> o fol r+ r�osl <br /> Distance to nearest: Well Foundation Property Lin U l7 ,2 <br /> 1 i?_ <br /> LEACHING LINE 11 No. & Length of tines Total length/sPh I " <br /> FILTER BED ❑. Distance to nearest: Well Foundation PrJiNA4 RGA' LEAL HEALTH DiViSiON <br /> 1 � <br /> SEEPAGE PITS 11 Depth f Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - . .r �. -• ..: J <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 shall not <br /> employ any pe rso in such manner as to beco subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies.the full ing: "I ce fy that in the pe rmanca of the work for which t 's perm' is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C rnla." <br /> The appli an m st call f II a it s s. Complete drawing on rev rse e. <br /> Signed X Title: Date: <br /> aw FOR DEPARTMENT USE ONLY p� <br /> � 4 <br /> Application Accepted by Dare 19Z Area f� f <br /> Pit or Grout Inspection by Date Final Inspection by Date=67 Z <br /> Additional Comments: 712-- f IL <br /> t we[f c o r.d Ce�r. If f4k__ l <br /> Applicant - Return all. copies to: San Joaquin County Public ealth If <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PE:RMI7'NO. <br /> r EN 13.21 IREV.i 10%SI �e- 4 T�` LLZ <br /> EN11-2s. T-H <br /> .,�,. .�---•rte =:.. <br /> F <br />