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+cti APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> L® ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468=3420 <br /> P 0 BOX .2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Co pie , e ' n Triplicate) <br /> Applicationia her y made to San Josrlit to construct and/or install the work herein described. This <br /> application Se made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San j <br /> Joaquin County Publi Ec <br /> l h Service. <br /> Vr'X,,",t i dW OC J`10Job Address VIr jl C City ro Lot Size/Acreage <br /> 1 ' X25'//Oa <br /> Owner's Name ►"r Address 4942 Phonef5-ro 847-b910 <br /> E #lid s s l ut 4376 3-�, R <br /> Contractor rte rt C. SGi _ {`✓Address-&-l. ` 34o}f <br /> License No. 065-13 Phone 1 S -618 <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 out or Service Well Cl <br /> PUMP INSTALLATION f) SYSTEM REPAIR 0 OTHER W�1 C7 i <br /> S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 1 I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10�S 1t <br /> f..l Industrial 0 Open Bottom ❑ Manteca Dia. of WAIT Excavation 96 Dia. of Well Casing <br /> ('.I Domestic/Private 0 Gravel Pack G1 Tracy Type of Casing_,..._.. Specifications <br /> I'I Public 6edi�� 1 fa Other n Delta Depth of Grout Seal ype of Grout <br /> t I Irrigation`& — Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work pone U Type of Pump H.P. State Work Oona _ <br /> Well Destruction 0 Well Diameter _ Sealing Material i Depth N <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I RF.PAIR/ADDiTION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve:- Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soft to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg 'Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method'of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE C1 No, 8 Length of lines Total length/size <br /> FILTER BED r❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS t I Depth Sixe Number <br /> SUMPS LI Distance to nearest, Well Foundation. Property Line <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 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 follow' : "I certif 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 Ca orn <br /> The applicant st all to at r wr ns r s. Complete drawing on verse side. <br /> rrV�41� /L C- a�` , <br /> Signed X Title: _ Date: 7 <br /> _.,. <br /> FOR EP RTMENT USE ONLY <br /> Application Accepted by Dateeas/ <br /> Pit or Grout Inspection by Oats 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 AMOUNT DUE AMOUNT REMITTED x RECEIVED BY DATE PERMIT NO, <br /> INFO H <br /> EH 13-64(Rev.1t96r C� <br /> 6H 14.26 - <br /> a t1(/ <br />