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APPL ICAT ION ? <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EMIRES I 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 in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 49Arg V a City Lot Size/Acreage <br /> 1C.Owner's Name Address aZ2 Phone <br /> r ,t <br /> Contractor Addressed i icense No.Z� b Phane <br /> TYPE OF WELL/FVIM5 NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 13 SYSTEM REPAIR 1 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing <br /> K Domestic/Private 0 Gravel Pack7 ❑ Tracy Type of Casing— Specifications <br /> V1 Public I-1 Other n Delta Depth of Grout Seal Type of Grout �n <br /> I I irrigation _.Approx. Depth 1 I Eastern Surface Seat Installed by <br /> Repair Work Done (A Type of Pump H.H.P. State Work Done a <br /> Well Destruction ❑ Well Diameter Se&iing Material & Depth <br /> Depth Filler Material & Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I ! DESTRUCTION I k 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Fsg*Me r <br /> PKG. TREATMENT PLT.0 Me <br /> Distance to nearest: Well Foundation Pfoperty L rUM ' <br /> LEACHING LINE Cl No. A Length of lines Total Iength! - Kk 3'i T <br /> NN <br /> FILTER BED 1=1 Distance to nearest: Wall Foundation Prop <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <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, stale 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on rev se side. <br /> Signed X Title: i � _ Date: <br /> DEP LY / <br /> Application Accepted by Date a <br /> Pit or Grout Inspection by Date Final Inspection b Dat �c1%f . <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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY /-� DATE PERM11'ttNttO. <br /> . EM t3-24I11EV.riNel r _ ' 0 <br /> EM i3-24 �lt r f <br />