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l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ��� j �� (� aDf�aD(hJ City Lot Size/Acreage <br /> Jab Address <br /> y Address G �' Phone <br /> Owner's Name <br /> Contractor <br /> ci_F Address M License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR.❑ OTHER ❑ <br /> Monitoring Well L7 <br /> DISTANCE TO NEARTIC TANK <br /> SEWER LINES DISPOSA PROP. LINE <br /> �._ .•.F-0UNDATI �=-�'�=AGEiIGULTI�RE:WEkL�=V-�p._�- _-. R-WEL-LS---�� <br /> "--.-- ". - ;PITSYSUMPS-== - <br /> INTENDED USE TYPE OF WELL �'PROBLEM cF tCONr TION SPECIFICATIONS /F <br /> Open Bottom Clanteca '" is.p . cavation Dia. of Well Casing <br /> Cl Industrial ❑ Ope �.- --�� <br /> + I�T e of Cas n� Specification <br /> C:1 Domestic/Private ❑ Gravel Pack ❑ Tr + Yp i 9:.� <br /> Cl Public <br /> -1 Other alta 3 DeGroutGrout Seams Type of Grout <br /> I I trrigation Appro epth I I Eastern Surface Seal Installed' } _ <br /> Repair Work Done L3 Type of ump H.P. rStata Work Done _ <br /> Sealing Material & Depth L2J € 0 <br /> Well Destruction ❑' Well Diameterj I 0 <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I OESTRUCTiON IIVa septic system permitted it public sewer is IL <br /> , <br /> available withi'rti 200 feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedroomsG, j <br /> l 1 . Water table depth <br /> Character of soil to a depth of 3 feet: 1 <br /> f <br /> + Y N t ripaci y No. Compartments <br /> SEPTIC TANK.; ❑ Type/Mfg {� ��p <br /> PKG. TREATMENT PLT. ❑ I � ��T` Mf�e°�t�R6fNii;. <br /> t 11 T- <br /> Distance to nearest: 1AFe11 Foundation r Propert� <br /> _ O <br /> LEACHING LINE L1 No. & Length of lines Total length/si <br /> FILTER BED f_7 Distance to nearest. Well Foundation Prof y0'AMITY <br /> SEEPAGE PITS l 1 Depth Size Numi�elJst ,0jj <br /> -„r- .,= $z-v F un atran r r Line <br /> SUMPS— � Y ""Lt-rDlstan7 a to nearest, Well o d P oPertY <br /> DISPOSAL-PONDS-0- <br /> l <br /> 1 I hereby certify that I have prepared this application and that the w&0,.will bedonen accordance Wifh San.Joaquin county ordinances, state laws, and . <br /> k rules-and-reguiations of the San Joaquin County"""""""�"r �- <br /> Home owner or licensed agent'ssignalure certifies the following; "I certify that in the perfotmance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <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,rnust call for all r ted ins ions. Complete drawing on rave a side. <br /> Signed X Title: Date: 2- <br /> k FOR DEPARTMENT USE ONLY <br /> Application Accepted by r Date � Area <br /> Pit or Grout Inspection by Date J Final Inspection by Date f 7� <br /> i <br /> Additional Comments; <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED 4 CK III RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> t . EH 13-24(REV.I/w 51 SZ) ! -* 7' � 7 !! '� ���(7 60 <br /> EH 1l-26 % <br />