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(�3 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 �+ 4� �n City 64_ Lot Size/Acreage <br /> Owner's Names �►�II�-�S Gl� Address 15-5- �� 00 <br /> "74elrAII& Phone <br /> � � is' �F� <br /> Contractor ddress Asn 4/ n en-se- No. Phone <br /> TYPE OF WELL/PUMP: NEVVVELL ❑ WELL REPLACEMENT FI DESTRUCTION O ouk of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER G21dSS ittoorriing 1 r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C&4-AZ <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. ____ State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth Q h <br /> Depth Filler Material & Depth (') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ir. <br /> available within 200 feet.) IT, <br /> 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 D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <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 rst call f all r uired i�syactions. Complete drawing qn r verse si <br /> Signed X fit, � r I r• k Title: Date: 111--16-` <br /> 13 <br /> �FOD=TMENTSE ONLY <br /> elr <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: r <br /> Applicant - Return all copies to: San Joaquin County Publ c Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. <br /> ♦ EH 3 24 EH 11.24(REV.1i85) INFO �� SH <br /> L_6-7 _ D 3 <br />