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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 /> 1 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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ,.� <br /> Job Address�.l�� t �""� Cd1� CitytnSize/Acreage <br /> Owner's Nam, ��%�J1/E �/" G( _ Address CgtA '&_I� lyw Phone L Q <br /> Contractor -- <br /> s ( icense No. Phone ^ <br /> TYPE OF WELL/PUMP: NEW W WELL REPLACEMENT DESTRUCTIONA Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK IM-)6. SEWER LINES DISPOSAL FLD.1W PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-- 61 <br /> industrial �❑/Open Bottom Manteca Dia. of Well ExcaDia. of Well Casi <br /> bQ <br /> Domestic/Private R�Gravel Pack ❑ Tracy Type of Casing_vatio PC — Specifications <br /> I'I Public 1-1 yOtthel n Delta Depth of Grout Seal 112705 Type of Grout <br /> I I Irrigation / ttyApprox. Depth I I Eastern Surface Seal Installed by il PY <br /> Repair Work Done ❑ Type of Pump H.P. S I one _ <br /> Well Destruction O Well Diam Sealing Material & Depth f( <br /> Depth Filler Material & Depth < SLS <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 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 Cl No. & Length of lines Total length/size <br /> FILTER BED Cl 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 ❑ <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 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for all r�edinspe.ctions. omplete drawing on rev side. <br /> Signed Title: - Date: 12-., <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z_ as 2- <br /> Pit orout spection by Date ���z{tinal Inspection/b / Dattt��� <br /> Additional Comments: , G:� <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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. `7/ <br /> . EH t3-24(REV.I/it sl W n / <br /> EH t4•2s <br /> WA <br />