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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 N O(AJ �. <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i[�z <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 /> Are <br /> Job Address .1 / Y Lot Size/Acreage <br /> ,4 z, <br /> +.t /�� �1Z <br /> O�sar's-Name- _- --Address.��A/r! - -.Phone. <br /> Contracto WFKw Address Llc se N,pa!pt�9-43 Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring W611 0 <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 /> ❑ Industrial ❑ Open Bottom 5 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> CL Doqiestic/Private ❑ Gravel,Pack L7 Tracy Type of Casing_'­w ^--- ------ Specifitations t <br /> I'll Public 11y GI Other n Delta Depth of Grout Seal Type of Grout <br /> I IIrritjHuon ;y ; _Approx. Depth I I Eastern Surface Seal Installed by f <br /> Repair Work Done 0 Type of Pump_ _ _ H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter "`_ Sealing Material & Depth--' <br /> Depth Filler•Material.& Depth 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION lNo septic system permitted if public sewer.is <br /> available within 200 feet.) <br /> Installation will serve: Residence A, Commercial_ Other <br /> ` Number of living units: Number of bedrooms <br /> J Character of.soil to a depth of 3 feet: Water table depth 3 <br /> rSEPTIC TANK. 'i >r,Type/Mfg _ Capacity t No. Compa►tments t <br /> PKG. TREATMENT PLT.Q :. "' '1- '- Method of Disposal <br /> Distance to nearest: .e Well i `� `J foundation Property Line <br /> LEACHING LINE Cl No. & LeA6ih,gf°liner:- � _ *� Total length/size <br /> FILTER BED C 1. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 1• Depth Size Number 3 <br /> SUMPStl Distance to nearest: Well Foundation t Property Line <br /> DISPOSAL PONDS ❑.__ 4 � <br /> s <br /> I hereby certify that I have prepared this application'and that the work will be done.,in accordance with San Joaquin ctunty ordinances, state laws, and <br /> rules and regulations of the San Joaquin-County f <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 subisct,to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perlormence of the W"ork for which this permit is'issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.- <br /> The applicant must call for all required ' specti S. Co�mple rawing on reverse side. 1 <br /> I€ / C <br /> Signed X =Title: p * „•• _••_ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date l Area <br /> Pit or Grout Inspection by °' ' Data' -Final lnspecbon`bv Data <br /> Additional Comments: Y <br /> $ Applicant - Return all copies to: San Joaquin County Public Health Services t <br /> Environmental Health Permit/S(krvides. <br /> 445 N San Joaquin, P 0 Box 20 �y Stkn, CA 95201 <br /> ' fEE <br /> INFO <br /> AMOUNT D& "k, OUNT,REM_ITTED CASH RfuCfIIVE,D'BY GATE e.•t PERMIT'Nb. <br /> EH13-24 IAEV,r i�S!EH �. l,(J�/ .� -K�Mw... - -. -.+tee" _ •_/�+�^�- f^ ✓ .-.�3� �/�. .�. _..e �..,e.�.ay <br /> r <br />