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f !� APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ( 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Seryt ices. <br /> %Job Address City Lot Size/Acreage <br /> ki <br /> Owner's Name Address AJC. [ Phone "3ai <br /> Contractor Addres's 3,6 License No. rPhone <br /> TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Ser exwell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER Q °nitaring well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES XD,1SPF65S;A�L�FLD._,PRi5P. LINE <br /> FOUNDATION + AGRICULTURE WELL_ O7HER WELD PITS/SUMPS w ^ � <br /> INTENDED USE TYPE OF,INELL PRO BLEM,AREA ,;,,GO9 TRU CTI OWSPECIEICA710NS <br /> C] Industrial ❑ Open Bottom E]Wanteca" Dia, of.-WeltEitcaveiion Dia. of Well Casing <br /> Domestic/Private '❑ Gravel Pack „G?"Tracyfi Type of-Casing_. Specifications <br /> l'1 Public 1-1 Other n Deha�-f ¢ De pth of Grout Seal Type of Grout <br /> I i Irrigation __ .Appro><: Depth fi"II E stem Surf oco Seal Installed by <br /> Repair Work Donft]-�"Type of Pum _" H.P. ! State Work Done — <br /> ' � Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> —Depth �70 Ffller'�Material & Depth <br /> E <br /> TYPE O�_WORK: NEW INSTALLATION I I REPAMIADDITION I. I DESTRUCTION I k INo septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> inatalietion will serve: Residence Commercial_ Other e <br /> E Number of living units: Number of bedrooms ° <br /> Character of soil to a depth of 3 feet? �,- Watet'tom9 <br /> SEPTIC TANK ❑ Type/Mfg ' ' Capacity No. <br /> � <br /> PKG. TREATMENT PLT. ❑ Methgdtgf Dilos� <br /> Distance to nearest: Well Foundation Props Y f lJe `F <br /> A OA <br /> LEACHING LINE CI No. & Length of lines Total IqM Air � 10 rq <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line IMlVfrIV FAL LTH DIVISION <br /> SEEPAGE PITS I I Depth Size �` Q Number <br />` SUMPS """ il=l—Distance`tounearest: Well Foundgticrn-' Pro <br /> party-Lina---=.T�: <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in ac'cordanwstate with San Joaquin county ordinances, ate laws, a <br /> rules and regulations of the San Joaquin County 1 <br /> r Home owner or licensed agent's signature certifies the following: "I certify that in the perftirmance.of-the woik 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 fol) 'ng: "I certify that in the performance of the work for which this permit is issued,Lahalr employ persons.eubject to workman's compensa- <br /> tion taw o if nla." ; ` r,.rV/ <br /> I�\ <br /> The appli t ust call for all reau' inspeCtia Complete drawing on raver side. *, <br /> e <br /> � t <br /> Signed Title: 09 4 ADate:- <br /> FOR DEPARTME USE ONLY <br /> Application Accepted by "�" Date t � / Area <br /> Pit or Grout Inspection by f Date Final Inspection by Date <br /> 1 � i <br /> Additional Comments: <br /> 7 t <br /> Applicant - Retarn all-.copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Service's # <br /> 445 N San Joaquin, Box 2009, Ston, CA 95201 <br /> INFq AMOUNT DUE AMO, T REMITTED CK RECEIVED By, ATE PERM17'NO. <br /> • EH 17-24[REV.tins <br /> EH 11.26 ' ' <br />