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e ADPL T CA° I ON <br /> SAN JO Q TY PLIC HEALTH SERVICES <br /> ENVIRONMENT TH DIVISION <br /> 445 N SAN JQAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> CSO <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. his <br /> application is made in compliancewith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 8 r es. <br /> Job Address tt <br /> r City tet/ 00K Lot Size/Acreage l <br /> Owner's Name T1 114� r v`B Address 54"" t <br /> rPhone <br /> Contracto _ 55 Address f� � � "� cense No y? 1Phone <br /> TYPE OF WELL/PUMP: NEW WELL r WELL REPLACEMENTi DESTRUCTION n Out of service well ❑ <br /> VI PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring fWell f �� <br /> DISTANCE TO NEAREST: SEPTIC TANK 12 - SEWER LINES DISPOSAL FLD._(L, PROP. UNE �(J <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ttt__ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` J/ <br /> •r <br /> n Industrial ❑ Open Bottom EIManteca Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Private I[Gravel Pack ❑ Tracy Type of Casing_- Specifications <br /> Il Public C7 Other fl Delta Depth of Graut Seal « tis Type of Grout. <br /> I I Irrigation 3-%.Approx. Depth I I Eastern Su ace Seal Installed by <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 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LI No. & Length of lines Total,length/size ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <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, 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 /> •ion laws of California." <br /> the applicant st all forI r ui a inspections. Complete drawing on reverse side. 1 <br /> S;gned Title: 0 /,�Date: � �y <br /> yy FOR DEPARTMENT USE ONLY <br /> 1, <br /> Application Accepted by Date Area <br /> el <br /> Pit r rou spection by Data b Final Inspection by Date <br /> Addi^ionai Comments:Qlt� l a4 rP& <br /> Applicant - Return all copies to: an Joaquin County Public Health Services <br /> Environmental Health Permit;/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> F AMOUNT DUE AMOUNT REMITTED 5 RECEIVED BY DATE PERMIT'NO. <br /> F L // . <br /> EH 53-2t IREV. <br /> EH 14.2e <br />