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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION F <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. -� i <br /> Job Address �� (.J� �`�{-� � City Lot Size/Acreage <br /> Owner's Name l Address Phone <br /> Contractor Rjd4,,YDS - ddress 12='Q License No. S7 _�__�__A Phone 44 <br /> TYPE OF WELL/PUMP: NEW MLL ©. WELL REPLACE NT C DESTRUCTION C Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR C OTHER C Monitoring Well L7 Jt <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 .4 -C Open Bottom C Manteca 'alis. of Well Excavation pia. of Well Casing <br /> ,[I Domestic/Private Gl Gravel Pack L1 Tracy Type of Casing_ Specifications <br /> I"j'Public Cl Other n Delta Depth.off Grout Seal Type of Grout <br /> t I Ifrigation Approx. Depth I I Eastern y-.Surface Seal Installed by <br /> Repair Work Done! 17 Type of Pump H.P. State Work Done <br /> Well Destruction F.p..Well Diameter Sealing Material i Depth <br /> 1 DepthFiller Material i Depth V" <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION Ii REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is ( -t <br /> available within 200 feet.) V <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: _ <br /> I�r _�1'lh _ _ � '` � Water table depth <br /> SEPTIC TANK _© Type/Mfg rte__ __ �_ Capacity No. Compartments i <br /> PKG- TREATMENT PLT. ❑ , X Method of Di oa I <br /> distance to nearest: x Well � N Foundation � Property Line- r <br /> _ _ 5 <br /> LEACHING LINE 1 No. & Length of linesa ,DiTotal length/size ov <br /> FILTER BED ❑ Distance to nearest. k.Well oa Foundation I �CProperty Line L} t A <br /> SEEPAGE PITS IJ Depth Size Number V' <br /> SUMPS , LI Distance to nearest: Well Foundation Property Line ,- <br /> DISPOSAL PONDS ❑ b. • - - - Y Q <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 7 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shell 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 /> sonifies 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 for all requ' d ' ctions Complete drawing on reverse side. <br /> Sign Title' Date: �a �� <br /> FOR DEPARTMENT USE ONLY !f f <br /> Application Accepted by Date b� Area ��-t L <br /> Pit or Grout Inspection by Date Final Inspection by 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 O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE FERMIT'NO. <br /> • EH I3d1 1AEV.1/0" <br /> 0 <br /> EH 1-I'mt 1 , 3 r ®V <br />