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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 PAYMENT <br /> P O BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 12 1993 <br /> (Complete in Triplicate) SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or inetfiNVIRIMr #$� qq�' QQy�{{��IIThis <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules�>7egut`iond'Si' San <br /> Joaquin County Public Health Services. <br /> Job Address City pZ--,Lot Size/Acreage <br /> Owner's NameAddresses Phone <br /> Contrac R 4ddre� <br /> 4n2goyicense r � � Phone � � <br /> TYPE OF WELL/PUMP: NEW WELL ❑^ � WELL REPLACEMENT F1 DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Indu I ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing –7 <br /> omestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications i <br /> 1'1 Public C1 Other n Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation Approx. Depth I l Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. _ State Work Done �rri� <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth !, <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I f DESTRUCTION I t lNo 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 r <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal + <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ 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 I <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I comity 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 California." <br /> The applicant must all required insptESIghs. Complete drawing on erre side. <br /> Signed X Title: <br /> Date. + <br /> R-DEPARTMENT USE ONLY <br /> Application Accepted by Date AYC Area <br /> f <br /> Pit or Grout Inspection by Date Final Inspection b ._ Dat <br /> Additional Comments. <br /> Applicant •- Return all copies to: San Joaquin County Public Health Services j <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> . EH 17.21IRt1r.1in51 I� ' o-0 ♦ � r!" �V 1 '� �� <br /> EH t4.2a '�`J• `E l 7 OW <br />