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!� I APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> a '' 445 SANR �AQNw � <br /> UIN,, HONE (209)458-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> I . <br /> _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J� (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with than Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health rvices._ s <br /> ob Address ' ��' �� / �4 City Lot Size/Acreage <br /> wrier Nerh 144 ddress Phone <br />� VVV��►►►` , <br /> 4yonllarOF <br /> ctor 1 Address License No. Phone <br /> W"'ELL/PUMV2 NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ <br /> i� PUMP INSTALLAT"IE Q Y, PAIR ❑ OTHER O Monitoring Well ❑ <br /> e DISTANCE TO NEAREST: SEPTIC <br /> FOUNDTANKTION A RICU I E L I P ELLD P TSI/SUMPS <br />{ <br /> INTENDED USE TYPE OF WELL RO M E�,A "S qf4k CATIONS <br /> Cl Industrial; O Open Bottom AaCTG7� ' ol, Favauon Dia. of Well Casing <br /> t 1 91QQ���° <br /> 11 Domestic/Private ❑ Gravel Pack. T,rac�`J ype o'i Ca ng S% f� Specifications <br /> 1'I Public I1 Other ' "TSI Delia'� 1Ftal. t�,. Type of Grout <br /> r I I Irrigation, -Approx. Depth I.I Eastern Surface Seal Installed by <br /> Repair Work Done IJ Type of Pump. H.P. `State Work Done_. <br /> Well Destruction ❑ Well Diameter^$ ., Sealing Material i Depth <br /> " Depth j Filler Material & Depth 4 � J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTICQ (No septic system permitted it public sewer is <br /> availablefwithin 200 feet.) <br /> Installation will serve: Residence Commercial_ Other a <br /> Number of living units: Number of bedroomk <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments, <br /> PKG. TREATMENT PLT:O Method of Disposal <br /> Distance to nearest:. Well Foundation:. Property Line <br /> LEACHING LINE ❑ No. enL pih of linea '� �� *Total le grit/size <br /> FILTER SED, ❑ Distance to nearest: Wel) Foundation Property Line " <br /> SEEPAGE PITS I I Depth 11 Size Number <br /> SUMPS ti Ll Distance to nearest: Well 'Foundation Property Line <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 /> rules and regulatiwts of the Sen 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 /> r employ any person in such manner as to become subject,lo workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performands of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> he applic7ust call for ail requ' inspections. Complete drawing on reverse side. <br /> X 5 <br /> igned �� R /� _ Y Title: �� �� oats: d~ . <br /> 1♦: r v <br /> ` OR DEPARTMENT USE ONLY <br /> iL <br /> ._ . <br /> Application Accepted by Dale c1 ?= Area d <br /> d <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> a <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Bax 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY I 9ATEf PERMI-r NO. <br /> . EH 13.24 IREV.mast <br /> EH -D r `L /11.26 / 1� / VWALA2 <br /> i I� <br />