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APPLICATION <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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ go _ City Lot Size/Acreage <br /> Owner's Name Address - __ Phone <br /> Contras Address L License Phone � 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> E-7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> Il Public El Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Ifrigation / Approx. Depth I } Eastern Surface Seal Installed by <br /> Repair Work Done --fid' Type of Pump H.P. �f State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material 8 Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 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 bedroomsC <br /> Character of soil to a depth of 3 feet: J 3 A14AS'N'epth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. 0 et o oll"osal <br /> r� 11 <br /> Distance to nearest: Well Foundation Pr c I�. � <br /> (Z i <br /> LEACHING LINE ❑ No. & Length of lines Toowm <br /> TH 0� <br /> FILTER BED C) Distance to nearest: Well Foundation <br /> SEEPAGE PITS 11 Depth Sim Number <br /> SUMPS LI Distance to nearest: Well Foundation --- Property Line <br /> DISPOSAL PONDS 0 <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 /> tion laws of California." <br /> The applicant must call igr all required igspe ions. Complete drawing on re rse side. f f <br /> Signed X Title: Date: L ` Y <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Y Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO \� �jc^ ( p �j 193 <br /> /�)a <br /> . EM13-24(REV.1/N5t1QK � y"' ��4`a / -�l (7 ~01, <br /> EH 14.26 i <br />