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r <br /> APPLICATION 3,0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--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'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> Job Address. trT�� <br /> OrV 'lJtrf'r/ ��/w 6tyswao& Lot Size/Acreage <br /> Add.,ress Phone <br /> Owner's Name r <br /> Contractor — <br /> ��6ress ' License Na�—Phon - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL PLACEMENT DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYS M REPAIR I� OTHER <br /> Monitoring Well ❑ <br /> DISPOSAL FLMQ227PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION rAGRICULTURE WELL,t�� OTHER WELL =: PITSISUMPS <br /> INTENDED USE TYPE OF WELL-- -PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation <br /> Specifications� ----- <br /> Dorrtestic/Private Gravel Pack Q Tracy Type of Casin _ <br /> ' <br /> Type of Grou Depth of Gr 1 <br /> I'1 Public. . `_ice-1s0�th./��r pp h r+-G�'r"7 _..... ._ <br /> 1 I irri{lation " ap�fSx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Don Type of Pump H.P, State Work Done <br /> Sealing Material k Depth �/ft�/� {` „d <br /> Well Destruction elJ��arneter vl` <br /> Filler Material & DepthDe <br /> _~ <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION I I [Ndiiable sept within system ranted it public sewer is <br /> f <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 0 Type/Mfg Capacity No. Compartments . <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> lk <br /> LEACHING LINE C1No. S Length of lines Total length/size <br /> FILTER BED ❑ Distance.to nearest:,—.,,r.—well—_.—Foundation ,Property.Line. <br /> I SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordi6arices, state laws, and <br /> rules and regulations of the San Joiquin 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or stab-contracting signatwe <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 /> The appli t u II or all r if {Tinspeetions. Complete drawing on r rse side. <br /> Signed <br /> Title Date• <br /> FOR _O LY <br /> 3 Application Accepted by Date X,� Area <br /> Pit r rou! spection by Date Final Inspection b at <br /> Additional Comments: <br /> Applicant - Return all copies to: San J n County Public Health Services '���/ <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'.NO. <br /> INFO <br /> ..-EH t3-74 0 V <br /> {REV:1/-N W �. 63 C'.r s� ./•-.... ,.-.w--a...� �O/ _. f... .� <br /> EH 14.26 r/ <br />