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APPLICATION FOR PERMIT No <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �� <br /> ENVIRONIMTALiHEALTH DIVISION <br /> 445 N F SAN JOAQUIN, 'PHONE. (209)46$-3420 �D SS r 6IL <br /> P 0 BOX 2009, STOCKTON, CA. 95201 f•�rT�; <br /> PERU EXPIRES Y FROM`D TE ISSN <br /> (Complete in Triplicate) <br /> Application is hereby de to San Joaquin County for a permit to construct msand install the work herein described. This <br /> 1 <br /> ma <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules end Regulations of San <br /> Joaquin County Public Health Services. <br /> t.- <br /> �`� T _ City �' Lot size/Acreage <br /> Job Address �„ � _ <br /> Phone C1 r <br /> Owner's Name /l1 fJ Address <br /> i. «. <br /> Phone <br /> Contractor <br /> @� �# Address License No. �- <br /> TYPE OF—WELL NEW WELL ❑ ' WELL REPLACEMENT In DESTRUCTION ❑ Out of <br /> Serring Well11 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ _ _ OTHER ❑ <br /> DISTANCE NEAREST: SEPTIC TANK SEWER LINES <br /> D L FLD.� PROP. LINE <br /> DATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WEL BLEM ARE NSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C3 Industrial ❑ Open Bottom ❑ a is. of Well Excavation - <br /> Specifications <br /> F :1 pomastic/Private ❑ Gravel Pack ❑ Tracy Type of Type of out <br /> 1.1 Public L OI " Delta Depth of Grout Seal <br /> 11 <br /> t Approx. <br /> — .Depth 1 I Eastern Surface Seal Installed <br /> I I Irrigation by <br /> Stats Work Done <br /> Repair Work Done Type of Pump H.P. _ <br /> I — -; Sealing Material i Depth <br /> Well Destruction O Well Diameter <br /> Depth tiller Material i Depth . <br /> '1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 lost.) <br /> Installation wBl serve: Residence I Commercial_ 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. O Type/Mfg Capacity No. Compartments <br /> PKG.`TREATMENT PLT.❑ Method of Disposal <br /> r. Distance,to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> I FILTER BED z. ❑ Distance to nearest. well Foundation Property Line <br /> f � <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS LI Distance'to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thi's 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 certify that in the performance of the work for which this permit is issued, I shah not <br /> empty 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 folbwing: "I certify that in the perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." J, -} <br /> f The applics at call for all wired Inspections. Complete drawing on reverse side. �r /Cl n <br /> I Signed 2 <br /> Title: Date: �/ , <br /> -eve r. -Gl FOR DEPARTMENT USE ONLY l <br /> Application Accepted by <br /> I Date 2 g 2— Area � 1 <br /> Pk or Grout Inspection by Data final Inspection by Date <br /> ro <br /> Br�r <br /> Additional Comments: y <br /> I <br /> Applicant -- Ret rn 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 /> FEEKAM;OUNT DUE!. A PUNT REMITTED AS RECEIVED BY 'DATE PERMIT'NO. <br /> INFO <br /> hL+ EM1124IREV,tinem774'0 11 � <br /> +' EN 11.25 <br /> 1 <br />