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APPL I CAJ�I'ON <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC -HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, -PHONE (209)468-3420 <br /> P 0 BOX 20099 STOCKTON, CA 95201 <br /> C,. P PQ,to(,�/�- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <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 Address Y i / <br /> / , J cars ezCity 0 Lot Size/Acreage <br /> Owner's Name KJ _3CAddress sc, t.�^' �i Phone �r� <br /> l f I <br /> Contractor �-C� d .alt Address K2 Aic- License No * Phone - — <br /> A k <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ) OTHER O Monitoring Well Li <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 /> Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , O <br /> YDomestic/Private ❑ Gravel Pack 11 Tracy Type of Casing_ Specifications <br /> Il Public _ 1-1 Other !' ❑-Delta .^•Depth of Grout.Seal Type of Grout <br /> I I Irrigation _ Approx. Depth I I Eastern Su ce Seat Installed by <br /> Repair Work Done Type of Pump �rr H.P. _ State Work Done c <br /> ls& Depthi <br /> t <br /> M <br /> Sealing aera <br /> Well Destruction ❑ Well Diameter Sea , <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION, 1_I' DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Resid6 ce-- Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity # No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal f <br /> Distance to nearest: Well Foundation Vroperty Line <br /> a� <br /> LEACHING LINE L1. No. & Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well Foundatii rh Property Line- / <br /> SEEPAGE PITS 11 Depth Size _ __ NumberY <br /> SUMPS LI 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 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, (shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 appfica c for all required peciions. Complete drawing on revers ide. <br /> Signed Title: ` Date: <br /> R D PARTMENT USE ONLY <br /> Application Accepted by Date U sea <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services I <br /> Environmental Healtt/Services <br /> 445 N San Joaquin„ ox 2009, Stkn, CA 95201FEE <br /> j <br /> INJO I.MOUNT DUE AMOUNT REMITTED I C K 11 RECEIVED BY /jD TE PERMIT'NO. /7/] <br /> + EH -24 IREV.i/n 51 ! '/ _ F/• �L./ -f <br /> EH 14 74.24 <br /> l <br />