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4, <br /> AN, J4JAQUIN Couwry PuuLA,.C1 R�P_Lni <br /> T11 <br /> ENVIRONMENTAL aEALTH .-DAIVISIOR <br /> !F C, BOX 2009 , STOCKTON , CA. 95201 IIJ N <br /> k209.) 468-3447 <br /> R=1T EXPIRES I YEAR FR014 PATEQJV1WNV1EN AL H EA;1. <br /> (Complete J.n 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 Sem Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address City-aAa.-. Lot. Size/Acreage <br /> Owner's Name ai ,zt- Address Phone <br /> Contlacto Address cense N Phonet :35, <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT [_'i DESTRUCTION Ll Out of Service Well. 0 <br /> PUMP INSTALLATION C�_ SYSTEM REPAIR OTHER C Monitoring Well ri <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 /> ;I-) Intl fill 0 Open Bottom anieca Die. of Well Excavation Dia, of Well Casing <br /> ;'15omestic/Priyate 0 Gravel Pack D Tracy Type of Casing Specification <br /> L� Public Cl Other 0 Delta Depth of Grout Seal Type of Grout <br /> 1:1 Irrigation /`',Approx. Depth C] Eastern it Surface Seal Installed by <br /> Repair Work Done Q_ Ty of Pump H.P. 1_6=== - State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth . <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDiTION 0, DESTRUCTION 7-1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence — Commerciat— Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C. Method of Disposal <br /> Distance to nearest: Well Foundation — Property Line W <br /> LEACHING LINE 0 No, 8 Length of lines Total length/size <br /> FILTER BED ci Distance to nearest: Well Foundation ___ Property Line <br /> SEEPAGE PITS I Depth --Size Number <br /> SUMPS LI Distance to nearest: well Foundation__ — Property Line <br /> DISPOSAL PONDS 0 <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 cenify 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 /> The applicant must Sp for all required insp#ctions. Complete drawingon <br /> �averse side, <br /> Signed X Title Date: <br /> F RZ�PARTMENT USE ONLY <br /> Application Accepted by Date 617//9- <br /> Area <br /> Fii 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 DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT-TED CASHRECEIVED BY DATE PERMIT N0. <br /> INFO <br /> ,,I ^ - . 4 __—_1_ d %A A <br />