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APPLICATION <br /> •• r r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-34200 1 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> OCT 16 199 <br /> ,PERMIT. EXPIRES 1 YEAR FROM_DATE_ ISSIN t. �,,.„ <br /> (Complete in Triplicate) 'SRF;°�`� <br /> TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork here&&R ffad. 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 `l Lot Size/Acreage <br /> wner'a Namn f�ddress� Phone <br /> t <br /> t►or 2 <br /> No. e hon�� <br /> TYPE OF WELL/PUMP: NEW WE L O WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well., ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> �striCI In trial m ❑ Open Bottom �'D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> al Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications <br /> i"1 Public M Other.' F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation k 3 Appiox;De h I I st n ce Seal Installed by ` <br /> Repair Work''Done :%L7 Type of Pu H.P. State Work D <br /> Well Destruction, �O Well Diameter Seating lZterial & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is (� <br /> available within 2W feet.I V <br /> Installation will.serve: Resident-a'"'��"Irommercial— Other w <br /> Number of living units: '°,,rNumber of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. }L ❑ Type/Mfg � �` Capacity No. Compartments <br /> 1 <br /> PKC. TREATMENT,PLT. ❑ � , '" � 4 � Method of Disposal � <br /> Distance to nearest: Well'""'*-�1Found6ti6nm^` Property Line <br /> LEACHING LINE ,s Cl a No. Length of lines Total length/size <br /> FILTER BED F 0 Distance to nearest: Well Foundation Property Line <br /> i F } <br /> SEEPAGE PITS F I I' Depth !I t Size Number <br /> SUMPS s ,. L1- {Distance to nearest: Well Foundation Property Line <br /> —DISPOSAL PONDS-:.._.__D�:s-,r a. .,..»3,•r - _ <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 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 /> The applic ust calLfor a iced i poptions. Complete drawing on c�alsed . <br /> Sig ed Tit date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 0;2// <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 Sox 2009, Stkn, CA 95201 <br /> FEE IN O AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVEED77 BY /DATE PERMIT'NO. <br /> : EHt3.24iREV.rinss <br /> EH 14'20 �r <br />