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d <br /> APPLICATION <br /> r <br /> - -.. .-:SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESe <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN"JOAQUIN, PHONE (209)46$-3420 �� �,�y -�c• <br /> P O BOX 2009, STOCKTON, CA 95201 i <br /> t' <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 City Lot Size/Acreage 5 V X I <br /> Owner's Name r Address <br /> r <br /> Contractor ,� J� Address License No. Phone U <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service well ❑ <br /> PU STALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring weld ❑ �� <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS U <br /> INTENDED USE TYPE OF WELL PROBLEM STRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Me Dia. ell Excavation Dia. of Well Casing <br /> f:l DomesticlPrivate TYPE OF <br /> Pack Tracy Type of Casing_ Specifications <br /> Il Public l_� Other ❑ Delta Depth of Grout Seal Type of Grout �+ <br /> 4 I I Irritation pprox: Depth ll Eastern Surface Seal installed by <br /> Repair Work Done Type of Pump H.P, State Work Done — <br /> Well Destr ' n r❑ Well Diameter Sealing Material & Depth <br /> r "'Depth Filler Material 6 Depth _ r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> i available within 200 feet.) I l <br /> Installation will serve: Residence Commercial T 'Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth'of 3 feet: Water table depth <br /> ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> S x it <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS - 11 , Depth Size Number <br /> SUMPS LI 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 regulations of the San Joaquin County ' <br /> k 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 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 /> j The applicaall Zkod inspections. Complete drawing on reverse side, <br /> i Signed X_= e Title: W rf7 �` ^� Date <br /> R D FITMENT USE ONLY r <br /> Application Accepted by ✓` Date �h Area <br /> Pit or Grout Inspection by Date Final.Inspection by Date <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 0 Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT AEMIT"I.ED CASH RECEIVED BY DATE PERMIT NO: / <br /> . EH 13-24 IREV.t/n 51 t)yd "7'�. -�• ��C / /i7 f j�Q'� i <br /> EH 14.25 <br />