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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 /> (^Cofn�lee din rTriplicate) <br /> Application is hereby made.to Senn 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 /> � s ! , <br /> Job Address _ ' WGity Lot Size/Acreage f t 3 �� <br /> Owner's Name !r ■ - --- Address ,L �` Phone <br /> 1 <br /> Contractor r - Address License No_Z?CX!;�W Phone <br /> TYPE OF WELL/PUMP: NEWWELL-0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well E] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1 FOUNDATION- AGRICULTURE WELL , OTHER WELL i PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom t . r ❑ Manteca `Dia` of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> FI Pubtic I-1 Other n Delta Depth of Grout Seal Type of Grout j <br /> I I Irrigation — Approx. Depth I 1 Eastern Surface Seat Installed by j <br /> Repair Work Done 17 Type-of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material 4 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION V.—DESTRUCTION I I (No septic system permitted if public sewer is <br /> r available within 2W feet.) <br /> Installation will serve'Residence c/ Commercial'— Other <br /> Number of living units: Number of b rooms _ .A <br /> Character of soil to a depth of 3 feet: - 1" Water table depth d P <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1]1�_No. & Length of lines 01 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well r Foundation Z�Q Property Line l <br /> SEEPAGE PITS 14--Depth S` I Size f Number <br /> SUMPS LI Distance to nearest: Well S6 r Foundation C16 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 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 1 <br /> cartifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica m camel io all requir i pe ons. Complete drawing on reverse side. , <br /> Signed Title: _ � Date: <br /> FOR DEPARTMENT USE ONLY ��1 <br /> Application Accepted by S - Date LQ 0 "°1 Z-� Area �7 <br /> 1 <br /> �it or Grout Inspection by ate '� �`�2 Final Inspection by 1 � � `� Date <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies 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 /> s , <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT-N0. <br /> 1''?••EH 13.2 i0.tw.t/n sl �� - // � - / � ,,, 9 - <br /> EH 11-25 <br />