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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 3aa Joaquin County for a permit to construct and/or install the work herein described. This i <br /> application Se made in comopliance.yith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen <br /> Joaquin County Public Health Services. <br /> r <br /> Job Address <br /> City Lot Size/Acreage <br /> Phone 0 <br /> Owner's Name ddress � <br /> 7.�' r /� � ✓� _ , <br /> f„ev G,r dress r` /�✓ ��' - License No,yyLG9aPnone ���SG <br /> Contractoill <br /> TYPE OF WELLlPUMP: NEW WELL 71WELL REPLACEMENT 11 DESTRUCTION L) pitt of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ <br /> OTHER p Monitoring Well <br /> -- SEWER LINES -&- DISPOSAL FLD. PROP.'LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK $— ,�.. <br /> FOUNDATION '�—- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> on <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavattiijon� 1 <br /> Dia. of Well Casing <br /> Type of Casing__'—� Specifica 'ons <br /> fit-roomestic/Private bevel Pack I-] Tracy <br /> r � <br /> I'I Public I.7 Otter Cl Delta Depth of Grout Seal __ TYpe'of-GroutP - <br /> I ( Irrigation ;� pprox. Depth I I Eastern Surface Seal Installed by 1 <br /> "S't,fj H P 1,S' Stat*Work Done <br /> of Pum <br /> Repair Work Done U Type p Sealing Material b Depth u <br /> Well Destruction ❑ Well Diameter - — Filler Material 8 Depth <br /> Depth <br />` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION i I availablelw thin 20c system 0 feet.) it public sewer is I1. <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Water table depth �./ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal Q <br /> _ - PKG. TREATMENT PLT. Cl ••;-- <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED n Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I neve prepared this application and that the work will be done in accofdance 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 foilowing; "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: 111 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 C i'fornis." r <br /> The appti nt mus call for rA1 required inspections. omplete drawing on <br /> 1reverse side. <br /> Signed Title: .S S„'. _ Date. ro <br /> rDIFOR DtPARTMENT USE ONLY <br /> Date ~ Area + 1 <br /> Application Accepted by <br /> A Pito Grout l spection by <br /> pate .Fi I Inspection by Date <br /> // v <br /> Additiofial Comments: <br /> Applicant - Return all copies to: San Joaquin County 'Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaqu O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH IVED BY DATE PERMIT ND. <br /> INFO <br /> . EH 13-24(REV.1"5s '"'^' <br /> l EH 14.20 <br />