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3 r <br /> • ter' ' APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> !, 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT:EXPIRES 1 YEAR FROM DATE ISSUED <br /> may.^_ w ...,..(Compzete 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publics Health Services. <br /> Job Address __ /Yoe /1�`✓ /'Q /f 0/1 City Lot Size/Acreage <br /> Owner's Name 1"7 o -r[. m.. 1l _® <br /> k rrurAddress /�ydo e cde,e_ryfaC Phone B <br /> Contractor i' �` ' rdr Address Y000 oV (sy_ - License No.-e?�Z��Phone — W O7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public [:1 Other n.Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approxi Depth I IEastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing'Material & Depth O <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is <br /> I 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 �cr� <br /> SEPTIC TANK IA T Capacityle6?0 No. Compartments <br /> YP 9 �r1 c.r.s <br /> PKG. TREATMENT PLT. ❑ ----// Method of Disposal <br /> -Distance.to nearest: We_II _2Z_ Foundation —.2Q Property Line 94„� <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance 10 nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS <br /> El Distance to nearest: Well � Foundation Property Line � <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared Ihis;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 tojbecome subject to workman's compensation laws of California." Contractoes hiring or sub-contracting signature <br /> certifies the following: "1 certify 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." f <br /> The applicant $t call for a squired inspections. Complete drawing on revers side. 1 <br /> r 1 <br /> Signed Title: Date: .(_ y <br /> F R DIE PARTMENT USE ONLY g ^� <br /> Application Accepted by r Date lT Ares ® .� <br /> Pit or Grout Inapection by Date Final Inspection b Date <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 Box 2009, Stkn, CA 95201 <br /> FEE 11E <br /> UE AMOUN REMITTED CK RECEIVED BY DATE AERMiT'NO. <br /> EH 14.21IREY.fisSiEH 11.2a <br />