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APPLICATION <br /> SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN; PHONE (209)468-3420 <br /> P 0 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 in 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 I � ,Y City ���[�-4 i of Size/Acreage <br /> Ovrner"s^Name MWJe Address Phone <br /> Contract !_ �- -- Addres icerise Na Phon <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION;❑_.Out of Service Well ❑ <br /> PUMP:INSTALLATION ❑ � c SYSTEM REPAIR ❑ OTHER O Monitoring Well` <br /> DISTANCE TO NEAREST: SEPTIC TANK LSEWER LINESDISPOSAL FLD. PROP. LINE <br /> 3 <br /> FOUNDATION AGRICULTURE WELL OTHER_WELL----- _---.. ,PITS1SUMPS• 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCAT•IONS ¢ t. <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `Dia. of Well Casing' <br /> F1 Domestic/Private ❑ Gravel Pack ❑ Tracy :Type of Casing_ Specifications— <br /> F] <br /> pecifications I'1 Public 1-1 Other F1 Delta, f-'Y-Depth of Grout-Seal (Type of Grout <br /> 11 irrigation —Approx• Depth- l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Weil Destruction ❑ Well Diameter Sealing Material,i.Depth <br /> 4 Depth Filler Material b Depth �� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 low-1 <br /> c <br /> Installation will serve: Residence Commercial__-_. Other f ' <br /> "„'Number of living units: Number of bedrooms � ^ / IN <br /> Character of soil to a depth of 3 feet: Watel table depth <br /> SEPTIC TANK ZAIf 57M Type/Mfg Capacity No. Compartments <br /> 6 PKG. TREATMENT PLT. ❑ „. ' —Method of Disposal <br /> Distance to nearest: Well Z=1--Toundation Property.Line <br /> 1 <br /> LEACHING LINE rT No. S Lengtfi of lines &V0 Total len t <br /> ' FILTER BEDj�-y-f] Distance to nearest: Wet! Foundation Property Ina , <br /> SEEPAGE PITS I I Depth Sire Number - r <br /> SUMPS LI Distance to nearest: Well Foundation Property Line 1. <br /> DISPOSAL PONDS ❑ � <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." o, <br /> Thea applicant ust call for all r >"• ; <br /> pp aqui din cions- Ca lets drawin n reverse side.,, <br /> Signed Title: Date: -/� <br /> L <br /> DEPART ENT USE-ONLY ,�.. .,. <br /> Application Accepted by S2L .,_ Date Area C7 12— <br /> Pit <br /> ZPit or Grout Inspection by Date Final Inspection by-,T-ej,9c Da[ <br /> Additional Comments <br /> r 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 95201FEE <br /> �V <br /> f l INFO AMOUNT DUE AMOUNT REMITTED CASH Cy RECEIVED BY DATE PERMIT NO. <br /> + EH 14.264 <br /> l-24JREV.,inal C Ily <br /> (C7� �� [f <br />