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f + 0 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 /> r <br /> PERMIT EgPIRES -1 YEAR FROM DATE ISSUED <br /> (COmplete in Triplicate) <br /> Application ie hereby made to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> Application is made in ecsPliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health lsrvices. <br /> Job Address 7 City Lot Size/Acreage <br /> Owner's Name G� ._ SSC ID Address <br /> Phone <br /> AA r <br /> Contract o 1 n r Address l <br /> ALAelLicense NotD.SStZ <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL-REPLACEMEN DESTRUCTIONOut of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER 0 Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES 1 � DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE.WELL �_E� OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial O Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 14.00mesticlPrivateravel Pack 1 [1 Tracy Type of Casing_- � Specifications <br /> V) Public C] OtF�er j0144!17 Deha Depth of Grout Seal <br /> V � ype�of Gout <br /> ! Irrigation -2CjW Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work pone U Type of Pump H.P. State Work Done <br /> Well Destruction � Well Diameter l / Sealing Material & Depth <br /> i <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION f I REPAIRIADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is V } <br /> -` available within 200 feet.) ! <br /> -Installation WIII Se Ne: RBSidBRC@ 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 <br /> Method of Disposal ' <br /> Distance to nearest: Well Foundation iProperty Line <br /> LEACHING LINE D No. & Length-df lines ` <br /> Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation _ Property Line <br /> .fit! <br /> SEEPAGE PITS 11 Depth Size . <br /> Number <br /> SUMPS Ll 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 for all refire <br /> Signed d inspections. Complete drawing on reverse side. <br /> X <br /> C <br /> _ l v ` <br /> Title: �esJ � <br /> .. .. ___._ Date: <br /> �! DEPARTMENT USE ONLY �f f <br /> Application Accepted by Date <br /> r h/ <br /> Pit or rou Inspection by Y at Final Inspection by Gc ZS ' <br /> r Date <br /> Additional Comments: <br /> qqq .r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ejk.,. <br /> Environmental Health Permit/Services `�s! ir�W•�V. lfr1�f71/�.�,j-ri"L J I' <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 "rA J J <br /> FEE Ir� �rll,p►4 <br /> R AMOUNT DtJE AMDUNT REMtT7ED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 IREV.r i n 5S •,,`W:';n i1,M 4 y <br /> EN 14.76 w�/ p �� [/ � � /fir r <br />