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APPLICATION <br /> ° } ,. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f ENVIRONMENTAL HEALTH DIVISION ! <br /> G� : 3d 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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 mate in compliance with San'.loaquin County Ordinance No. 51+9 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �n <br /> Joh Address 1~yIN� � Cit Lot Size/Acreage <br /> ,: tt ; t /Ifo <br /> ..�-Owner=s Named =�— Address �.�����-- __ - _— Phone <br /> Contractor S Address /zj5-011 Licdnse N Pho <br /> TYPE OF WELL/,PUMP: - NEW WELL f-1WELL REPLACEMENT 17 DESTRUCTION ❑ Rut- of Service Well 0 <br /> ► } .,PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl -,,Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF: ZINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial © Open Bottom ❑ Manteca Dia. of Well-Excavation_, Dia. of Well Casing <br /> °"- f l Domestic/Private ❑ Gravel Pack ""❑ Tracy Type of-Casing_ - Specifications <br /> I'I Public C1 Other nDelta Depth of Grout Seal TYPe of Gro t <br /> I I Irrigation. ; —Approx. DepthI I Eastern Surface Seal Installed by <br /> Repair Work Done r 0 Type of Pump H.P. State Work pone <br /> a Well Destruction ❑ k Well Diameter _ Sealing Material & Depth <br /> z <br /> t Depth r Filler Material S Depth ! <br /> r <br /> P <br /> STYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION JX'DESTRUCTION I 1 1No septic system permitted if public sewer is <br /> available within 200 fest.l <br /> `l - <br /> Installation will serve..-: Residence X Commercial Other <br /> 3 <br /> Number of living units: __L_ Number of bedrooms� <br /> Character of.soil to a depth of 3 feet: Water table depth <br /> �C1ST'SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl - -M..- .--- ---- - Method_of_Disposal- <br /> Distance to nearest: Well Foundation Property Line \, <br /> `a <br /> A,r s <br /> LEACHING LINE No. & Length of lines, = _ i• ," ,ms `Tbtal'length/size � �, <br /> r� .- '- 's ) <br /> ^�FICTER 11 <br /> BED ❑ Distance to nearest: Wellns raundation �Proper[y f ms <br /> ins <br /> SEEPAGE PITSI I Depth Sixe __ N9mber i E. <br /> w <br /> 'SUMPS } dL Distance to nearest Web -Ca�r- Foundation Property Linek ` <br /> DISPOSAL DS s. ` LJ <br />` I hereby certify that 1 have prepared this:application and that the work will be,done in accordance with San Joaquin county ordinances, state laws, and, ' <br /> rules and rag0aflons of the San Joaquin County , t <br /> Home owner or licensed agent's signature certifies the following: ".I certify that iri the performance of the work for which this permit is issued, I shall not <br /> employ any person,in sttckmannir'is to_become subject to workman's compensation-laws of_Californiar;Contrrictor's hiring or subcontracting signature <br /> tartifieti the follow '1 certify that in the performance of the work for which this permit is issued, I shall employ-persons sulSjeot to workman's carnpensa- <br /> i tion laws of California.". <br /> s applican must call for all reg ' ins tons. omplate rawi reverse side "' _ <br /> Signed Till -%Q • Data: <br /> OIR P9 AR MENT'USE ONLY, <br /> s M <br /> I , { +. �Dats 1.7 �-- .` Area G <br /> Application Accepted by _QQr.� L <br /> .a- i s"4_ ; �� T L.r 4 r�� t ♦� 4 f`� i !~ r � f <br /> Pit or Grout lInsfpe7 ction by Date ^Fintil Inspection"by `Date <br /> Additional Comments: ` ' <br /> Applicant - Return all'reopies to:. San Joaquin County Public Health Services a <br /> n. 'Environmental Health Permit/Services <br /> `445 NiSan, Joaquin, P Oh Box 2009; S'tkn, CA 95201 ` <br /> FEE AMOUNT DUE"' AMOUNT REMITTED CK RECEIVED EKY„ _ TE � PERMIT'NO. ' <br /> INFO <br /> l� a <br /> EH 1721IREV.r/hsf L -v-� •�'• �� <br /> EH 11•ZE ' <br />