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APPLICATION �T� �� •� <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 1s made in compliance with San Joaquin County ordinance No. 50 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address J d5 R _ City-ae"Vell t Size/Acreage <br /> Owner's,_Name „ - a Address d <br /> 1 ..One <br /> ContractorJA a4 a6t 4� Address , ),![yo >P License No Phone ^ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well 70 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TOJNEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1 - _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .INTENDED,PSE y.'J,. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F] Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F.h-Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing- Specifications o <br /> I'] Public f..1 Other-- n DeltaDepth of Grout Seal T p� <br /> ype of grout �y <br /> I'-I`frrigation ! , �.Approx. Depth I'I Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump. H.P. __ State Work Done # <br /> Well Destruction ❑ Well.Diameter, Sealing Material 8 Depth s 0 <br /> r �I Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic stem 11 a <br /> ` P y permitted if public sewer is <br /> available within 200 feet.) <br /> Ahstallation will serve: Residence k Commercial Other <br /> '., 3 J <br /> Number of living-wits: _/__ Number•.of bedrooms tai <br /> Character of soil to"a depth-of 3 lost:°r Water table depth <br /> SEPTIC TANK C , Type/M1g � L} apacty� No. Compartments <br /> PKG.tTREATMENTPUT s❑-,7 r <br /> y- ,,� Method of Disposal <br /> Distance to nearest: Well- /.7.� foundation Property Line <br /> i :II t r <br /> LEACHING LINE &� O.: & Length of lines ~,- '� Total length/size <br /> FILTER BED C7 Distance to nearest: WeII,[.���Fouridation._/%� Property Line <br /> SEEPAGE PITSJ:� 11 Depth Site ` Number <br /> UDf'l� 1 <br /> SUMPS ; <br /> x � Distance to nearest: Well Foundation� Property Line �D� <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 lawsand <br /> rules and regulations of the San Joaquin county , 111 <br /> Home owner-or Iicensed 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 folio wing: "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 for!9 required inspections. Complete drawing on reverse side. A <br /> Signed ! Title' �Cl7 Date: 4L2 <br /> OR PART NT USE ONLY <br /> Application Accepted by _4 Date reg_L <br /> Pit or Grout InspeIction by Date Final Inspection b Date <br /> Additional Comments: <br /> nt:: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health permit/Services <br /> i 445 N Sin Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE <br /> INFO SAMOUNT REMITTED H RECEIVED BY DATE PERMIT*NO. <br /> • EH 13-24 IREv.1/n51 <br /> EH,14-29 <br />