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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 rade to San Joaquin County for a permit to construct and/or install the work herein described. This 1 <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> R � <br /> Job Address City Lot Size/Acreage <br /> } <br /> Owner's Name _`,Address ' Phone <br /> ContractorDa—,,A�ss. License No. Phone&310 f <br /> TYPE OF WELL/PUM : _ NEW WELL ❑ WELL REPLACEME T C1 DESTRUCTION Out of service Well ❑ <br /> PUMP STALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well <br /> k <br /> DISTANCE TO NEAREST: SEPTICNK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> -.FOUNDATI AGRICULTURE WELL OTHER WELT. PITS/SUMPS .� <br /> INTENDED USE TYPE OF WEL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing <br /> (7 Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other '�'f 1 D�ta ept-of rotit�l Type of Grout 1 <br /> 1 1 Irrigation —Approx. Depth t I Easte S�,rface Seal Installs� y <br /> Repair Work Done L) Type of Pump i H. State Work Done <br /> Well Destruction ❑ Well Diameter Se ng Material k B th <br /> Depth Filler terial pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLAIJIONI 1 REPAIR/ADDITI I DESTRUCTION I o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence__._. Co mercial_ Other-' � <br /> Number of living units: Number of rooms f�g� <br /> Character of soil to a depth of 3 feet: ` Water table depth <br /> SEPTIC TANK. 0 Typs/Mfg Capacit No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal r <br /> Distance to near) t: W11I <br /> Foundation Property Lina , <br /> s [� <br /> LEACHING LINE Cl No. & Length ines of length/size <br /> FILTER BED C1 Distance to eargst: Well Foundation Property Line <br /> SEEPAGE PITS 1 1 Dept <br /> SUMPS L! D' ante to nearest: Well Foundation Props Line <br /> DISPOSAL PONDS ❑ @ <br /> I hereby certify that I haw prepared this application and that the wort will;be done in accordance with San Joaqut county ordinances, state laws, and <br /> rules and regulations o!fXhe San Joaquin County r, I <br /> Home owner or licenW 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 parsonA such manner as to become subject to workman's compensation laws of California." Contracior's hiring or sub-contracting signature <br /> certifies the following: "i certify that i rformance 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 applica ui d ins tions. Comp) to ing on reverse side. <br /> Signed Title: _ I Date: 4M111<2 "3 <br /> OR DE NT USE ONLY 1 <br /> Application Accepted by -� <br /> Date Area <br /> d � <br /> Pit or Grout Inspection by Date Final Inspection by \� Date 6 I <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 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMO NT DUE AMOLJ T REMITTED CK R VED BY ATE PERMIT'NO. t <br /> a EH17.26 IREV.r/x s1 So / ! �,,� 1 ' <br /> EH 1�4e / y <br />