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APPLICATIQN <br /> SAN JOAQUIN C6UNTY 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 /> f--,I- <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 / © S j4 /� City Lot Size/Acreage <br /> Owner's Name 1, zeAddress �� �- t, Phone <br /> Contractor AddresOV:2y/_ 2�. Z&%R License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CI DESTRUCTION O out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR/' OTHER O Monitoring Well <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 /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O 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. De th I I Eastern Surface Seal Installed by <br /> Repair Work Done tV Type of Pump H.P. 3 State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence e 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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O 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 C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size r_ Number <br /> SUMPS LI Distance to nearest: Well Foundation_ Property Line <br /> DISPOSAL PONDS O <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 must 11 for all required inspec'ons. Complete drawing on re e e side. <br /> Signed X Al Title: Date: <br /> D RTMENT USE ONLY <br /> Application Accepted by `-'�� _- r� s-;=� Date `�o``\ -\�-- Area Q `� <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 INFO AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO. <br /> . EH 13.211REV.1/M51 \ N,. Z&W V <br /> EH 11.2e <br />