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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES ] YEAR FROM DATE ISSUED <br /> (COmplete in Triplicate} <br /> Application 1s hereby made to Ban Joaquin County for g <br /> application is made in compliance with San Joaquin Countyor No. 5b9to Construct aendmit <br /> or install <br /> the theRules work herein described. <br /> Sans <br /> oaquin County Public Health Services. <br /> Job Address �. p 4r L� <br /> City T Lot Size/Acreage 49 <br /> Owner's Name 07 j <br /> Address I-S! �a Q <br /> Ph7 <br /> pp .� one <br /> ContractorlQ/'♦r.` a .�a Address leaO /✓ �,`/ d r��j, ����� <br /> TYPE OF WELL/PUMPcense No. cf� f1,� phone " <br /> NEW WELL ❑ WELL REPLACEMENT M . <br /> LATION ❑ DESTRUCTION L, Out of Service <br /> PUMP INSTALiJe11 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK UNDATIQN SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> SEWER LINES �` DISPOSAL FLD. PROP. LINE ❑ <br /> FO <br /> INTENDED USE �� AGRICULTURE WELL <br /> OTHER WELL PITSlSUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial ❑ Open Bottom ❑ Manteca <br /> fa Domestic/Private CDia. of Well Excavation7 Gravel Pack • Dia. of Well Casing <br /> 0 Tracy <br /> I'1 Public Type of Casing_ Specifications - <br /> f 1 Other f 1 Delta Depth of Grout Seal <br /> 11 Irrigation ­Approx• Depth I I EasternType of Grout <br /> Repair Work Done U T Surface Seal Installed by <br /> Type of Pump .�� H,P. <br /> Well Destruction ❑ WWI Diameter Seali State Work Done; <br /> ng Material & Depthr^� <br /> Depth ' Filler Material 6 Depth V <br /> TYPE OF SEPTIC WORK; NEW WSTALI.ATION I I REPAIR/ADDITION DESTRUCTION 1 <br /> INo septic system permitted if public sewer is <br /> Installation will serve: Residence �r available within 200 feet.I. <br /> , <br /> .4 Commercial Commercial�'�Other JJ _T <br /> Number of living units: —L Number of bedrooms �� pQ�!a o /�� �H <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Type/Mfg Capacity Water table depth ° <br /> d 0 <br /> PKG. TREATMENT PLT. ❑ No. Compartments C1 <br /> Distance to nearest: Well Method of Disposal <br /> Foundation tProperty Line <br /> LEACHING LINE >' No. & Length of lines r <br /> FILTER BED Total length/size ° <br /> Distance to nearest: Well FoundationO ° <br /> ----L-�. Property Line <br /> SEEPAGE PITS 1?r< Depth r° <br /> SUMP5 Number <br /> L I Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation_. Property, Line <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 11 <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 f <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 applicant t call for al uired inspecti ns. Complete drawing on reverse ids, <br /> Signed X ♦ <br /> Title: <br /> �. Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 2 <br /> Date , Area 1 <br /> Pit or Grout Inspection by <br /> Date ^ Final Inspection by G <br /> '�GDate <br /> Additional Comments: l f � <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK r <br /> INFO CASH RECEIVED BY DATE <br /> R r O PERMIT'NO. <br /> EH 13-24IAEV.ii�yi . I• r Q� <br /> EH 14.3e <br /> �3 IDD <br />