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AITLICATION <br /> SAN JOAQUIN COUNTY-PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 001 PERMIT EXPIRES 1 •YEAR FROM DATE ISSUED <br /> (Complete in, Triplicate) <br /> I <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 cenpliance with San Joaquin County Ordinance No.A49 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. wr/'_ V--a7— D 2 <br /> Job Address <br /> V f-it1V City' Lot Size/Acreage +' 3&,1 <br /> Owner's Name � � Address Q. Phone i <br /> Cantsactor vl Address �` �c License No.a27,01 <br /> =f'hon2 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Cl.Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR rOTHER [IMonitoring Well n <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 /> 171 Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l"Domestic/Private 0 Gravel Pack L] Tracy Type of.Casing_ Specifications <br /> t'1 Public t-1 Other n Delta Depth of Grout Seal Type of Grout <br /> �d'Irri{lation Approx. Dom, I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of PumH.P. _ '30 - ___ State Work D66e <br /> Weil Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R I REPAIR/ADDITION [ I DESTRUCTION I I .INo septic system permitted if public sewer is <br /> available within 200.feet.l i <br /> Installation wilt serve: Residence Commercial_____ Other j <br /> - Number of living units: " Number of bedrooms `. <br /> Character of soil to a depth of-3 feet: - Water table depth <br /> G SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments.' r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0. No. & Length of lines Total lengthlsize "- <br /> i <br /> FILTER BED- ❑ Distance to nearest: Well' . Foundation Property Line <br /> SEEPAGE PITS 11 Depth Six§, Number'• <br /> SUMPS Ll Distance to nearest:r s. Well '—'Foundation Property'Line <br /> a <br /> DISPOSAL PONDS D <br /> I hereby certify that I have prepared this application and that the wotk~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 cornpensatioh,laws of California:',Contractor's hiring or sub-contracting signature <br /> certifies the following: "I comity 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 /> �..., r <br /> The applic ust c for all required inspeetions. C plate drawing on rse aide. <br /> Signed Tide: �� '' _-- Date: <br /> �i <br /> t � <br /> Z , <br /> * - F DEPARTMENT USE ONLY <br /> Application Accepted by ���. i DateArea <br /> Pit or Grout Inspection by Date Final Inspection b 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, t_64ox 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE A OUNT REMITTED CK RECEIVED BY DA PERMWNO. <br /> INFO L,/ <br /> IE . EH 13.24(REV.1/H!1 T( ,< <br /> f <br /> 1 EH 14-25 111111 G.J <br />