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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <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 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 /> fCit Lot Size/Acre e i�Q <br /> R� a <br /> Job AddressVuwd � <br /> [J' CUass b <br /> Owner's Name `J �u SS --_ Address S 13eaye✓ �7 <br /> Coritiactor koe Address to 2 I License No. Phone? <br /> TYPE'-OF WELL/PUMP: NEW WELLY WELL-REPLACSMENT_C1 —DESTRUCTION i1 Out of Service Well Cl <br /> ° PUMP INSTALLATION 17 :'7. <br /> SYSTEM REPAIR L1 OTHER ❑ monitoring-Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD.�— PROP. LINE _eff_ <br /> FOUNDATIONS _ AGRICULTURE WELL .0— OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n IndustrialDpen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing (v <br /> D DomesticJ Private 0 Gravel Palk7 ❑ Tracy Type of Casing_ Specifications • <br /> I'] Public 1.1 Other C1 Delta Depth of Grout Seal ype of Grout T <br /> irrigation J...-Approx. Depth 1 I Eastern Surface Sedi Installed by "Qr^ <br /> Repair Work Done L3 Type of Pump H.P. to Work Done _ <br /> Well Destruction U Well Diameter Sealing Material & <br /> Depth Filler Materlorl Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> - available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: At Water table depth <br /> SEPTIC TANK. E3 Type/Mfg Capaci No. Compartments <br /> PKG. TREATMENT PLT.C) Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: W Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size — Number <br /> SUMPS LI Distance to nares Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this ap kation and that the work will be done in accordance witti San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin ounty <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 shat]not <br /> employ any person in such mariner 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 Caiiforni ." <br /> The applicant mus uire inspec Complete drawing on reverse 'de. <br /> SignedTitle: Dater <br /> FOR DEPARTMENT USE ONLY qp f <br /> Application Accepted by Date Z7e)/J2 Area_ + q2 �� ? <br /> , <br /> Pit or 41 Inspection by ate final Inspection by �'[ - Date 1 __L„2 <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 0 Box 2009, Stkn, CA 95201. <br /> PEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'N0. <br /> INFO �/t� CASrH_ Q� �j G'] <br /> a EH 13-24 EH11.�tREV.rinsr �� L3 �tr� 1 ,00 �o V �� 1� IL �� 01t�l . <br />