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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 0 BOX 2009, STOCBTON, CA 95201 <br /> RERMR IT 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 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 /> VJob Address J 1 ` J — N , City Lot Size/Acreage <br /> Owner's Name �L "" ���� Address �' r �`' p �— Phone `� <br /> VContractor LAj j,.), IF Address. _ License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t'1 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER O 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 /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f) Domestic/Private 11 Gravel Pack I"1 Tracy Type of Casing_. Specifications <br /> 11 Public ("1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I lrripation Approx. Depth 1 I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AERAIR/AODITiON I I DESTRUCTION/ o septic system permitted if public sower is i <br /> �''� av ilable within 200 feet.) <br /> Installation will serve: Residence— Commercial Othe 1 <br /> H, t:p <br /> Number of living units: Number of bedrooms <br /> 1 LA <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK O Type/Mfg _ 'Canachy ( ( Compartments <br /> �. O � Disposal <br /> PKG. TREATMENT PLT.O b { ���9�� (fir Ir7�p8l;��iod of Oi sal <br /> Distance to nearest: Well y �Vl� atio, roperty Line <br /> 1 talon <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED to Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS O <br /> 1 hereby certify that 1 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 subcontracting 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 /> The applicant t call tor all required insPections. Complete drawing 7verse <br /> /L�side. <br /> �igned Title: �/- Date: _4Z n4 zZ <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by 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, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH i RECEIVED BY DATE PERMIT'N0, <br /> . Em 13.24(REV.11145) t o—o <br /> EH 11.46 r <br />