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y . <br /> APPLICATION <br /> SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICES v <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 V I <br /> P O 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 incompliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. c. <br /> Klob Address �C �r^ City �� ��Lot Size/Acreage <br /> Owner's Nam ress Phone <br /> Contractor _ _Address License No. Phone If <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'} Public I:1 Other Cl Delta 'Depth of Grout Seal Type of Grout — <br /> I i Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. _-- State Work Done ViT <br /> Well Destruction ❑ Well Diameter sealing Material 6 Depth _ - <br /> Depth Filler Material yDepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DESTRUCTION A INo septic system permitted if public sewer is a <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg Capacity J. ­�No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ''S5 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. ffr Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> l 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." Contractof's hiring or sub-contracting signature <br /> certifies the following: "I certity 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 applicant must call fo all requirad ' coons. Complete drawing on reverse side. <br /> Signed Title: Date: T r 2l C� <br /> e5� T R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <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 O Box 2009, Stkn, CA 95201 <br /> FEE *'AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY" DATE PERMIT'N0. <br /> INFO CASHrrs,� 99 y� <br /> EH 13-21(REV.I/M5) -7tC7t7 c0 j o` '�t 13 � VC. <br /> 4 2-- <br /> EH t4.2e <br />