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APPLIr, TION <br /> SAN JOAQUIN COUNTY PUBLC HEALTH SERVICES <br /> ENVIRONh[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 1862 and the Rules and Regulations of San- <br /> Joaquin County Public Health Services. (� <br /> Job AddressO v City J Lot Size/Acreage <br /> c <br /> Owner's Name Address .Sri.- r� Phone <br /> Contractor` C— l � <br /> Address / J G L!-0 [� License No. d Phane. dZ <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well 0 I <br /> PUMP INSTALLATION O SYSTEM REPAIR)R7 OTHER ❑ Monitoring Well ❑ <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 /> n Industrial +.- p-Open Bottom s Dia. of Well Casing <br /> Pe . �© Manteca, `.. Dia. of Wail-Excavation <br /> Domestic/Private '""C7 Gravel'Pack , ElVa'cy Type of'Casin <br /> 9- Specifications r <br /> I'1 Public I-] Other 11 Delta Depth of Grout Seal Type of Grout_ <br /> I I krioation_ - y'. Approx, Depth _LI Eastern-.. _Su_ace_Seai-Installed by - <br /> Repair Work Done <br /> 247 Type of Pump H.P. _ State Work Done <br /> Welt Destructions El Well Diameter Sealing !Material 6 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms O <br /> Character of soil to a depth of 3 feet: r 1-41 Water,table depth <br /> SEPTIC TANK ❑ Type/Mf <br /> 9 ' Capacity. No. Compartments (� <br /> PKG. TREATMENT PLT.C} Mf Method of Disposal ' v <br /> Distance to nearest: Well Foundation �. Property Line I <br /> LEACHING LINE ❑ No. & Length of lines7rital length/size <br /> FILTER BED 7. <br /> Distance to nearest: Well Foundation Property Line <br /> SEEPAGE.PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepared this application and that the-work�will'bs 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 perlormance of the work for which this permit is issued, i shall not <br /> employ any person in such manner as to become subject to work me n'SL Compensation-laws of California." Contractor's hiring or sub-contracting signature <br /> can'laws olthe foll wing' I certify that in.the performance of the work for which this-permit is issued, I shalt employ persons subject to workman's compensa- <br /> tioThe appli t must for all required i spections. Com fete drawing on r ens side. <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by . <br /> Date Area v •� f <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments <br /> t <br /> Applicant - Return 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 /> FEE <br /> �O AMOUNT DUE AMOUNT REMITTED CK RECEIVED By <br /> INFO <br /> `�' DATE PERMIT'NO. <br /> • EH 14.2 !REV.r/n5) /f, 1"7 / <br /> EH 14-2E <br />