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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 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address 4Ltr ��� CitysPr9cro J tot Size/Acreage A bye 7s fx 140 r <br /> d.3n �a� sp rq $7 1s�t3y I <br /> Y- owner's NameC��(F3 ,/�t � 6 Address N1r,rseO '�f(Phone <br /> x Contractor 0 lat9&l K. Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C1 Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fi.d. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 industrial O Open Bottom ❑ Manteca Dia. of Weli Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing_ Specifications ' <br /> Fl Public 1-1 Other ;.-. 11 Delta - Depth of Grout Seal —.—Type of Grout <br /> — <br /> I I Irrigation _..Approx. Depth l I Eastern Suffaee Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ C6mmeicial='"Other <br /> Number of living units: Number of bedrooms x <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ 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 /> 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 cenify 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 required inspections. Complete drawing on reverse side. <br /> Signed x � e✓��+,.`� Title: Date: 3-2f <br /> - AMESI <br /> PARTMENT USE ONLY <br /> } eApplication Accepted by' L� W- �p flti`! _ Date C l�1Area IS - <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services "- £w C°fd S c.,*..-ec( <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201. V ` <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DSTEEg:6 <br /> INFO CASH <br /> . EH 13.24(REV,rrnsJ � -M �3ppG / <br /> EH 14*-2a f■f( <br />