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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 EgPIRES 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 /> City Lot Size/Acreage <br /> Job Address <br /> l Phone �3 <br /> Address <br /> Owner's NamelqaLAAL <br /> f/ <br /> ContractorLI <br /> Address 1� LIQ nse Noi��d� Phone �� <br /> &41a�- 2 <br /> TYPE DF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7.1DESTRUCTION LI Out of Service Well L <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER C3Monitoring Well C1 <br /> DISTANCE 70 NEAREST; SEPTIC TANK <br /> SEWER LINES — DISPOSAL FLD. PROP. LINE \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing <br /> CI Industrial O Ope \ <br /> Specifications <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Type of Grout <br /> I'I Public Cl Other n !]alta Depth of Grout Seal <br /> t I Irrigation —Approx. Depth I I Eastern Surface Seal installed by <br /> H p — State Work Done <br /> Repair Work Done {J Type of Pump gosling Material � Depth <br /> Well Destruction D Weil Diameter Filler Material & Depth <br /> Depth <br /> o septic system peTYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION DESTRUCTION I I availabe within 200 fffeettjed ii public sewer is <br /> installation will serve: Residence Commercial_ Other <br /> Number of living units: -t— Number of bedrooms <br /> Character of &oil to a depth of 3 feet: � �7 Water table depth `\ , <br /> SEPTIC TANK Type/Mfg Capacity ,lLCl1 No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <' <br /> Distance to nearest: Well Foundation 1S Property Line <br /> � <br /> Length of tines � Total length/size- <br /> LEACHING LINE�[� No. & g -�--- r . <br /> FILTER BED n Distance to nearest: Wail 400-4--nundation Property Line <br /> !i Nu ~ <br /> SEEPAGE PITS Depth Size Nun 12 <br /> SUMPS LI Distance to nearest: well /-�fFoundation�� -Property Line <br /> DISPOSAL PONDS ❑ <br /> ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <br /> rules and fegulations 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." <br /> Theapplica call for all r uire ins ctions.r Com to drawing on revefse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date 3 Area <br /> Pit or Grout inspection by Date — Final Inspection by Data <br /> r ✓ % -,W—et— <br /> Additional Comments: "* ,f,� 11ASpV „1 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ft7 �41 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO 01 <br /> . EM 13-24(REV.iin5) ,E ��y� 1/ya= Ql - ► �`� 9 -7�3 � <br /> EM 14.26 <br />