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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 /> (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 /> Job Address <br /> E,75." City Lot Size/Aere.g <br /> ''' "'�F`IT <br /> Address -116kPhone <br /> Owner's Na... //�,�j �s.• /� <br /> Agel <br /> Contractor <br /> jet A4? Address��. k�t>r License No. Phone <br /> of Service Well LI <br /> TYPE ELL/P MP: EW WELL ❑ WELL REPLACEMENT F1DESTRUCTION Out Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O <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 /> Dia. of Well Excavation Dia. of Well Casing <br /> n Industrial ❑ Open Bottom C3 Manteca <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of,Casing__ Specifications <br /> i'I Public f l Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. St Work qone <br /> Well Destruction � Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I JNo availabptic system <br /> m permitted if public sewer is <br /> le Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <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 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size �_— Number <br /> SUMPS LI Distance to nearest: Well Foundation 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, 1 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: "1 certify that in the perform ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Cal' is." <br /> The applicant u call all required in . Complete drawing on reverse side. <br /> '1 e s _ <br /> Signed X Title: � '��" Date: 7 �'`-°`- <br /> 417 <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Data ^9Z Area_5L <br /> PP <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO ^ �J r/QiQ <br /> . EH 13.24IREV.1/951 WD `o.00 CQ.Q W ( 1...- <br /> EH 14-26 Y� <br />