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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 oo wt-\-\ 0\jzir%eX- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -b VOL <br /> (Complete in Triplicate) �e�m��5• <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 /> 1, Joaquin County Public Health Services.X. <br /> Job Address �• >/f(,F �//l`_ <br /> City ST�// fJi�/ yot Size/Acreage <br /> L Owner's Name Address �a0 �- /Uri U� phone <br /> Contractor �SFL� Address License No. Phone i <br /> ;5 TYPE OF WELL/PUMP:_..�_NEW WELL ❑ . WELL REPLACEMENT_1--1 .,,_--DESTRUCTION_.Ll_Out qf:-Serylce-Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D �OTHEp G Mo ng Nell L7 <br /> DISTANCE TO NEAR ANK SEWER LINES DISPOSAL•FLD LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER W 4 '�- PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA TRUC CIFICATIONS I <br /> L-I industrial ❑ Open Bottom ❑ Manteca a We tion Dia. of Well Casing <br /> fl Domestic/Private ❑ Gravel Pack 0 Type of Casing_ Specifications <br /> !'I Public I.1 Other I1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation p0ok. Depth I I Eastern Surface Seal Installed by <br /> .1 RepWork D Type of;-Pump <br /> .F Hp,. F State Work Done , <br /> we <br /> H.P.ruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> ,TYPE OF SEPTIC WORK NEW INSTALLATION.1 1'- REPAIR/ADDITION I 1 DESTRUCTION 1No septic system permitted if public sewer is t <br /> available within 200 feet.) <br /> R <br /> Installation will serve: <br /> Residence_ Commercial-� Other <br /> Number of living units: , Number of bedrooms i <br /> Character of soil to a depth of 3 feet: } may— Tf <br /> table depth <br /> f <br /> 'SEPTIC TANK. ❑ Type/Mfg ..x� --Capacity No. Com artments <br /> PKG. TREATMENT PLT.Cl Method of isposal <br /> Distance to nea est: We ,Founds 'on <br /> Po +nL e f r <br /> a <br /> t <br /> LEACHING LINE ❑ No. & Length of 'nes Total Is th/size <br /> oll <br /> ijFILTER BED n Distance to neares all Foun ation open e # <br /> .. <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS I I Distance to nearest: Well Foundation <br /> C) Property tine <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 /> ruses and regulations of the San Joaquin County j <br /> eHome 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 /> mploy any person in such manner as to become subject to workman's compensation-laws of California."Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in'the performance of the work for which thii permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of C 'forma." 1 <br /> The applica st call for all r red ins ti s. Complete drawing on reverse side, k <br /> XSigned X <br /> Date: <br /> F N7 USE ONLY 'I <br /> Application Accepted by - Datel r _ Area <br /> Pit or Grout Inspection by <br /> Date—, Inspection by <br /> r - ...:y..-......_...,�.'._ - � <br /> Additional Comments: 1 0+✓i Pvt ` <br /> Applicant Return all .aojsJ66 to: San Joaquin County Public Health Services 1 <br /> P � �`_ "` 'Fdviri5iimeafaT Health`Permit/ServfcBeg <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. <br /> INFO CASH - <br /> . EH 13-24 1REV.+inss SD <br /> EH 1Lit <br /> 42a "'C <br />