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Q 2 APPLICATION <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �f P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i 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 Count Public Health Services. /� <br /> All Job Address f le Cit ? Lot Size/Acreag 0,e <br /> v-16wner'a NamePhone <br /> - � J # <br /> �+G%`J Address <br /> Contractor�1.�/ ddress License No. Phone <br /> TYPE OF WELT./PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Veil 77 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [-1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications— <br /> Il <br /> pecifications Il Public C1 Other F1 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 i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION iNo septic system permitublic sewer is <br /> I ailable within 2 . - <br /> Installation e: 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 - 0 Type/Mfg rtY No. Compartments . <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ation Property Line ]� i <br /> LEACHING LINE ❑ No. & Length nes ength/size <br /> FILTER BED C7 Dista o nearest: Well Foundation Pro Line <br /> SEEPAGE PITS 11 Depth Sire Number f I <br /> SUMPS I_I Distance to nearest: Well Foundation Property Line <br /> DI AL 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 la 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 F <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 Iowa ofalifornla." <br /> The applica t ust call f all ui d inspections. Complete drawing on reverse side. <br /> i <br /> XSned <br /> e rifle: Date: <br /> FOR DEPARTMENT USE ONLY � <br /> Application Accepted byA k 11 111r—tL. Date ~ 9 > Area , <br /> Pit or Grout Inspection by Date J Final Inspecti n by Dets <br /> Additional Comment:: -4=RA -c irc c �*- <br /> �. flea{ <br /> Applicant - Return all copies to: a Joaquin County Public Health Services � <br /> _., Environmental Health Permit/Services <br /> . _..y„F„r445 N,-San Joaquin, p O Box 2009,. Stkn, CA..95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKCAS <br /> RECEIVED BY DATE PEttM1T'NO. <br /> {� <br /> INFO H <br /> • £H 1 <br /> 3-71{REV.i/n 5f -!� r rJ �/ � <br /> EH 13.26 3 / tZI-06901 <br /> I <br />