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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALT� ARVCES �} <br /> ENVIRONMENTAL HEALTH DIV( IO� - <br /> .. 445 N SAN JOAQUIN, PHONE (209)468��20 Yq� <br /> P 0 BOX 2009, STOCKTON, CA520 <br /> 1 # <br /> if PERMIT EXPIRES 1 YEAR FROM DA E ISSUED <br /> ID <br /> (Complete in Triplicat r) ,:`t <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work ere <br /> application is made in compliance vith San Joaquin County, Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Jodquin County Public Health Services. <br /> 1 IE L <br /> Job Address Z-'vC. City Lot Size/Acreage <br /> /�(Jyc � 4�tC>� tX 2� G Address Phone 0� <br /> f Owner's Name �r svk (fj <br /> I If Z_/ G. License fro. C� � 7 Phone °`E ��-3 <br /> Cahtractor �' Address <br /> WELL RE ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ PLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ C7 <br /> f <br /> DISTANCE TO NEAREST: SEPTIC 7 SEWER LINES DISPOSAL FLD <br /> FOUNDATION RICULTURE WELL WELL PITSISUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Mantec Dia. of We ovation Dia. of Well Casing <br /> n omestic/Private ❑,Gravel Pack cy Type of Casing Specifications <br /> [ I'IkPublic to Other n Delta Depth of Grout Seal Type of Grout t� <br /> I Illrrrgation A x. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 of ump . H.P. State Work Done <br /> r Sealing Material i Depth <br /> Well Destruction ❑ Will Diameter <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION REPAIRIADDITION I } DESTRUCTION l I ;No septic system permitted if public sewer is <br /> ;`I a available within 200 feet.) <br /> Installation will serve: Residence Commercial^ Other <br /> .'Number of living.6nits: --/-- Number of bedrooms � <br /> (Character of soil_to a depth of 3 feet: Water table depth C <br /> SEPTIC TANK. X Type/Mfg" z�.L- Capacity^ No. Compartments <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Foundation�� Property Line <br /> i <br /> LEACHING LINE No. 8 Length of lines _ O � � Total length <br /> F,1 /size <br /> FILTER BED ID Distance to nearest; Well-F-Q- Foundation '.tea Property line <br /> SEEPAGE PITS Depth r�L� �- _Size Number <br /> SUMPS ul Distance to nearesr 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 /> r 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 /> arnpLoy any person in such manner as to become ubject to workmen's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I c et in the perfor once of the work for which.this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws li rule <br /> { The a lican75we <br /> II requi ed i drawing on re erse side. <br /> Sign Title: Date: <br /> t i FOR DEPARTMENT USE ONLY / <br /> i Application Accepted by <br /> Date r� 0 Area 1 L <br /> it Grout inspection by 10 to Final Inspection by <br /> k <br /> Additlonal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> i <br /> FJ <br /> Environmental Health Permit/Services <br /> �3 ;� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> E�INF <br /> I AMOUN7 DtJE AMOUNT.REMITTED �K RECEIVED BY DATE PEAMSIT'NO. <br /> EH 192 (REV.lixss { �D ' }1{ "`f e�LCJ <br /> EH 14.0 1 <br />