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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$•-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made•to Saw Joaquin County for a permit to construct and/or install the work herein described. This <br /> ance with San Joaquin County Or No. 549 and 1862 and the Rules and Regulations of San <br /> application in made in compli <br /> Joaquin County Public Health Servic s. ,r� <br /> i City Lot Size/Acreage L� <br /> Job Address <br /> Owner's Name <br /> Address- r/> C Phone <br /> " Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WEL , T Cl DESTRUCTION C} Out of Service well <br /> PUMPA <br /> eTLE <br /> q R ❑ OTHER ❑ Monitoring Well <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTAN S OTHER WELL PITS/SUMPS <br /> FOUNDA IONF" WIRUN r <br /> SPECIFICATIONS <br /> TYPE <br /> INTENDED USE TYPE O Ik B <br /> n Industrial ❑ Open W IV ant ca ��} ��p[�a f,W �ccavation Dia. of Well Casing <br /> �. <br /> P, r� t ` <br /> C . <br /> ; ` "' �0 asinlg__ Specifications <br /> Ll - <br /> F.) Domestic/Private Gravel iLJ jType of Grout <br /> ('1 Public Cl Other i r ❑ Delta Depth of rout Seal <br /> I I Irrigation Approk, Depth 11 Eastern Surface Seal Installed by <br /> H'.P. State Work Done <br /> Repair Work Done L7 Type of Pump <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth ',!- <br /> TYPE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I i lNo septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> f Installation will serve: Residence !�� Commercial— Other <br /> Number of living Unita:_ Number of bedrooms�2 _-- d <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. TypelMtg Capacity Zfl Me Compartments <br /> PKG, TREATMENT PLT. ❑ i Method of pispoaal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE CI No. A Length of lines Total length/size <br /> FILTER BED F) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ] Depth�f Sire Number <br /> SUMPS Gl Distance to nearest: Well Foundation Property Line # <br /> DISPOSAL PONDS ❑ "C <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 of 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 person in such manner as to ubject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "19 rtify at-W--th rfor ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Californ I . <br /> The applicant:nus all r I uired nape ron omplete drawing on reverse side, �-�^ <br /> Signed - <br /> Title: _� "''e - Date: U — <br /> { _ PARTMENT USE ONLY c, <br /> Applicati6n Accepted by ' � Date <br /> Area C) <br /> t � _Date_ Final Inspection by Date <br /> i -.,;.,'Pit or Grout Inspecuon_by� _ <br /> # Additional Comments:- f <br /> � � R <br /> Applicant - Return all copies to: San Joaquin County Public Health,Services N. ..�,, ; <br /> Environmental Health Permit/Servi'c'es <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> Y FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NQ. <br /> ` INFO CJ ��]� <br /> . EH 13'2.4 r/NS) ©� 1 r 00 , 7 `� /3 � W <br /> EH 14-m <br />