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r <br /> 6 <br /> APPLJ CATION <br /> e <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> to Q �w c f 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 /> I 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 /> t Job Address V City.. 0 Lot Size/Acreage <br /> Owner's Name �C &`LAddress 0./14— — Phone / <br /> Conlractof/mZ-f aak E Addresso. O� License N C C!Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR �' OTHER ❑ Monitoring Well C7 <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 /> Ci Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ <br /> X,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> CI Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout (� <br /> I I Irrigation _Approx, Dep l I Eastern Surface Seal Instafied by <br /> Repair Work Done 'Type of Pump H.P. r` State Work-Done \ <br /> Well Destruction ❑ Well Diameter Sealing Material 4 Depth <br /> Depth Filler Material d Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation w4i serve: Residence Commercial-L— Other " -r <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. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ,Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I 'Depth Size Number. <br /> [[[ SUMPS UI 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 iignature 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 /> Thea t must call r all required in clions. plate drawing onse side. a r { <br /> Signed Title: -4 Date: <br /> � � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by oata q2/ <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 Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY p TE PERMIT'NO. <br /> EH 13-24{REV.riKai <br /> _ EH 14-26 <br />