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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION 4` <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420P19, #"' _' <br /> P O BOX 2009, STOCKTON, CA 95201 g" { ;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 /> J CP Lot Size/Acre <br /> Job Address / � � c V�� City age <br /> /07.2- --5 2O <br /> Owner's Name Address/07.2- � �-+��hone /'� �� <br /> Contractor4"&_,(&A� <br /> Address rQ icense N0.1,&&0VZ Phone 2-19"- Ad <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION It SYSTEM REPAIR 0 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 /> ClIndustrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> M Domestic/Private 0 Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'1 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 1f, Type of Pump H.P.I State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth .4 ✓,r>slfl <br /> Depth Filler Material & Depth a `— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal _ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED O 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 O <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 <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 call n all required insPections. Complete drawing on r verse side. <br /> Signed Title: i�7b7�W54de Date: <br /> FIDE SE ONLY <br /> Application Accepted by Date ,� e r 0 <br /> Pit or Grout Inspection by Date Final Inspection <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 <br /> INFO AM��O``U��NT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EM 13.21(REV.I i x sl 41 bb 9 <br />