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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 E%PIRES -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.o <br /> l Job Address -��lC ltit f _ City , Lot Size/Acreage <br /> Owner's`Named—_ ;1 ••,„ [�- /�C Address Phone <br /> Vie- <br /> Kontiactar.. _ Address License tio. Phone 7S r5 <br /> TYPE OF WELL/PUMP: NEW WELL CJ WELL REPLACEIVItNT'Cl DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION O-'" SYSTEM REPAlR,_6. j OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES 4\DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL —'OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Ria. of Well Casing <br /> Cl Domestic/Private Cl Gravel Pack L7 Tracy Type.of Casing__ Specifications <br /> Ul Public C7 Other f1 Delta Depth of Grout Seal Type of Grout <br /> I l Irrigation —,.Approx. Depth I # Eastern Surface Seu'i Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter. _ Sealing-Material.& Depth VJ <br /> w + Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW XiNSTALLATIm, . .I s RJ 0 I I OESTRUCTEON 17 INseptic system permitted it public sewer is <br /> + vailable within 200 feet.i �kl <br /> Installation will serve:'"`Resiclence [.e p <br /> ,.--. <br /> Number of living units: Number of bad <br /> r ms �J <br /> Character of soil to a depth of 3 feet: r r � Water table depth <br /> SEPTIC,TAINK # ❑ Type/Mfg <br /> s� r pe aty <br /> 61 f No. Compartments <br /> by <br /> PKG. TREATMENT PLT. ❑ ti Method of Disposal <br /> - Distance to nearest: �l T Property Line <br /> LEACHING LINE 0 .No. & Length of lines Total length/size " <br /> FILTER-BED t_ _n - Distance.to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ; I I Deptti" Size __ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ 1 <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 oenifies 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 Compansa j <br /> _. lion laws of California." <br /> The applicanI must call for all required inspections. Complete drawing on reverse side. <br /> KSigned X <br /> _. Tills, Date: � �2 I_ <br /> Y <br /> F RTMENT USE ONLY <br /> Application Accepted by Date .2 `��� Area <br /> 15 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies! <br /> to: San Joaquin 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 a AMOUNT REMITTED CK <br /> INFO CASH �m RECEIVED BY DATE PERMIT'NO. � <br /> EH 14.26(REV.t i 8 SI <br />