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APPLICATION �"- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />` ENVIRONMENTAL HEALTH DIVISION <br /> O <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> /0 _ . P 0 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 CA0, /on, City 4 �i / Lot Size/Acreage Za X/ OO <br /> .01 <br /> Owner'sName CO 4.r,-7e Address de/� A—lip Phone d Ze <br /> Contractor a/' & fgn ___Address woe GvI _e"i License No.giU_"7V 5 .� Phone $ E_Y45;0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑.Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 /> f 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications A <br /> Public 1-1 Other n Delta Depth of Grout Seal Type of Grout (�\ <br /> I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> I Repair Work Done ❑ Type of Pump H.P. Stag Work Done ` <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth �3 <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITIONA DESTRUCTION I 1 lNo septic system permitted if public sewer is <br /> available within 200 feet)Installation wilt serve: Residence_X Commercial_ Other <br /> :Number of living units: __/_ Number of bedrooms <br /> I` Character of soil to a depth of 3 feet: C/a a, Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br />'i PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines �- O�_ Total length/size O _k -A X <br /> FILTER BED C1 Distance to nearest: WellrD Property Line _ <br /> �,.,-.. Foundation <br /> SEEPAGE PITS N. Depth ter Size rzct- _ Number' <br /> SUMPS 1;1 Distance to nearest: Well Foundation Property Property Line c2 <br /> DISPOSAL PONDS 0 <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 thisPe rmit 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 fotlowing: "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 /> Theapplicant st call for a uired inspect no. Complete drawing on reverse side. <br /> k Signed Title: �A _....__ Date: a-�/ . <br /> flJUPARTIMFNT USE ONLY <br /> Application Accepted by _ k,��Laes� K2 Data 1.? Area <br /> ZL" <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> �Z <br /> Additional Comments: r Q�, ) 7 <br /> Applic nt - Return all copies to: San Joaquin County Public Heal h Services <br /> — Environmental Health Permit/Services <br /> II 445 N San Joaquin, P 0 Box 2009, Stkn, CA^ 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NNO�. <br /> + EK 13.21(REV.rinse <br /> EK 14.20 L [ :a�L ?S <br />