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"- APPLICATION <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 1� X73 Zo.37m„o I <br /> 445 N SAN JOAQUIN, PHONE (209)46873420 <br /> JP 0 BOX 2009, STOCKTON, CA 95201y�-r � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> „J_ ,^ (Complete in Triplicate) 2 f3 —I 'a <br /> A ication is hereby made to San Uoaquin County for a permit to construct and/or inatall the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 n8622 and <br /> Address d the Rules and Regulations of San . <br /> ,rpt <br /> Joaquin County Public Health Services. N 2�j—�EjQ ��f 3 <br /> SwG m �}.,rz ,i City Lot Size/Acreage y M_ �tJ 6r�� <br /> sSL !r S—Nhone <br /> " �Owner's Name — �•� <br /> J <br /> Contractor <br /> ess".? � ��m Sr se No. Phone <br /> f TYPE OF WELLlPUMP: NEW WELL LJWELL REPLACEMENT C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 46-5 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Pieell G_Asi"g <br /> C7 Domestic/Private ❑ Gra4el Pack ❑ Tracy Type of Casing_ n°ns <br /> 1'1 Public 11 Other n Delta Depth of Grout Seal Typg'W-&Out d r� <br /> 1i Irrigation _.Approx.'1Depth 1 I Eastern Surface Seal Installed by <br /> If�,.-, � w ���� <br /> Repair Wort Done 0 Type of Pump H.P. — State Work Done <br /> 'Sealing Material i Depth 1F <br /> Well Destruction ❑ Well Diameter <br /> Depth' Filler Material 6 Depth <br /> iNo seTYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I V DESTRUCTION I l availablerwithin 200 feetsystem .) it public sewer is <br /> Installation will serve: Residence— Commercial— Other �Il <br /> Number of living units: Number of bedrooms <br /> Character of soil to s 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 C1 <br /> No. & Length of lines Total length/sire <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> ills <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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 signslu je 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 workmen'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 persons subject to workman's compensa <br /> '3 tion laws of California." <br /> j The applicant m call for all ed inspections. Complete drawing on reverse side. <br /> Signed X + Title: �&cS-) Date: <br /> 1 F PARTMENT USE ONLY <br /> :3 r <br /> ,i Application Accepted by Date Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by aA, I Dat <br /> Additional Comments: <br /> Et <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 C H RECEIVED BY ATE PERM17'NO. <br /> t INFO <br /> } ��Ii EN 135j6 ?q, <br /> EH 14-25 <br />