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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 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 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.Q �f t <br /> Job Address ` " 5 fp Ci,,drng40re1 LotSize/Acreage <br /> Owner's Name / Address ^ Phone <br /> Contractor ���� �r✓f4 4F4 Address YC2 f�{C1.�+i1/�/� License No,—, ` Phon <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 11 DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well <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 /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth �J <br /> Depth hiller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is r— <br /> � <br /> available within 200 feet.) <br /> Installation will serve: Residence I -commercial_ Other //,, <br /> Number of living units: __/_ Number of bedrooms_�_ b <br /> Character of soil to a depth of 3 feet: s eg du 1/ -.4_",L- Water table depth <br /> SEPTIC TANK O Type/Mfg 'F�,_Z L, Capacity 41Q 2_ No. Compartments <br /> PKG. TREATMENT PLT. O ( Method of Disposal <br /> Distance to nearest: Well 410-1-6- Foundation Property Line. (Q� <br /> LEACHING LINE No. & Length of lines C? �� Total length/sizeA /"—7- <br /> /�� V <br /> FILTER BED 1:1 Distance to�nsear-est�: - Well._ Foundation /�T Propertty, Line /6 ' <br /> SEEPAGE PITS 11 Depth __ Si:e_ � � � Number <br /> SUMPS 'bQ 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, 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 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f r all squired insPections. Complete drawing on reverse side. <br /> Signed X Title: 440- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '`'] <br /> ' �_q ' Area <br /> Pit or Grout Inspection by [ Date (� Final Inspection by <br /> Date <br /> L6 <br /> Additional Comments: 5!/Y1n f / X C) r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH R IV D4 1 ../ DATE Q PERMIT'NO. <br /> . EH 13-241REV.1/M5) /1 -00 _ /•4'J� ( / /�, /� <br /> EH 114-26 [ • <br />