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' APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Jb� <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 ra <br /> P 0 BOX 2009, STOCKTON, CA 95201. AP�C�ilNr <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISS U PU 4/ I0 R 1 1 19�® <br /> (Complete in Triplicate) IRSil-I <br /> �,FPUIN 3 <br /> J'-C(4(.6, :. 0s c�3 0 'I��TH COUNT <br /> 9" g <br /> Application is hereby made to San Joaquin County for a permit to construct and/or it5eta11 the work he�9 <br /> application ie made in 'ccmpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Aeg�i �¢ Sans <br /> Joaquin County Public Health Services. �SI <br /> , I!' L r ON <br /> Job Address • 'f City Lot Size/Acres e <br /> B TQ S <br /> Owner's Name Address _A3q 1�. /gyp}�[yPhone S92 <br /> # <br /> Contractor J <br /> � Address-� 3 - ".,"" License No. (o r Phone <br /> TYPE OF WELL/PUMP: 11; NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wel.1 ,. <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f 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 /> Cl Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> {, 11 Domestic/Private CliGravel Pack '❑ Trac Type of Casing Y yp gSpecifications <br /> I'1 lblic i--1�Other n Delta Depth of Greut Seal Type of Grout <br /> ? rigation Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump _ H.P. ' State Work Done <br /> Well Destruction 0 Wall Diameter Sealing Material &'Depth <br /> Delpth Piller Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I {No septic system permitted if public sewer is O <br /> available within 200 feei.I <br /> Installation will serve: Residence— Commercial _ Other ti S <br /> Number of living units: - I� Number of bedrooms <br /> Character of soli to a depths of 3 feet: Water table depth _ <br /> SEPTIC TANK. 0 ' Type/Mfg Capacity - No. Compartments <br /> PKC, TREATMENT PLT. 0 Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 ��No. & Length of tines Total length/size <br /> FILTER BED ❑ 'Distance to nearest:, Well Fouridation pr r <br /> il�i Property Line <br /> SEEPAGE PITS 11 i Depth Size Number <br /> SUMPS [l ",Distance to nearest: Well Foundation .Property Line <br /> _AiSPOSAL PONDS D <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 licen ed 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' scch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the follow' g 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 ' .4a." <br /> i The applica m call for all,requi a inspect' Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> i <br /> F R DEPARTME USE ONLY <br /> Application Accepted by Date <br /> Area <br /> II <br /> Pit or Grout Inspection by �!' Date Final Inspection by Date 73 <br /> Additional Comments: ll <br /> 6 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> Ili 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> IF <br /> 0 AMOUNT DUE AMOUNT REMITtED CK RECEIVED BY DATE PERMI7'N0. <br /> • EEH 3-24 FF 14-20(ACV,tins {�,�_ 4csf Sas fid' <br />