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' 'Ia APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420k —" <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> r <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1 C)o ni <br /> f oJ. Si,>ar_-c s d,4--C4(�- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work erein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 d the Rules and Regulations of San <br /> Joaquin Count Publi Health Services. 7 ZZ-2 <br /> Job Address <br /> 'yti City_ Lot Size/Acreage Q <br /> X' ��, ��o Z <br /> Owner's Nam A�e15� � Phone <br /> Contraclof Address License No. Phone + r. <br /> TYPE Of WELL/PUMP: NEW WELL.D WELL REPLACEMENT ❑ 4 DESTRUCTION Out of Service Well l i <br /> PUMP INSTALLATION C1 SYSTEM REPAIR C1 t OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:l Domestic/Private ❑ Gravel Pack 0 TracyType of Casing_ Specifications <br /> I'i Public ­ lfOther FI Deni` Depth of Grout Seal Type of Grout - <br /> L <br /> I I Irrigation r ' Approx. Depth l I Eastern Surface Seai installed by t <br /> Repair Work Done.,,.U Type of Pump t 2` H.P. �___ State Work Done_. t <br /> €�,,�• 6 <br /> Well Destruction (❑ •,Well Diameter -� Sealing Material Depth i <br /> P <br /> Filler Material b Depth <br /> �� Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 ° REPAIR/ADDITION I I DESTRUCTION 1.1.(No septic system permitted if public sewer is (n <br /> available within 200 feet.) ,P � <br /> installation will serve: Residence Commercial _ Other <br /> l <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth Q�t <br /> SEPTIC TANK. © Type/Mfg Capacity No. Compartments <br /> 4 PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: `Well Foundation Property Line <br /> i' A <br /> at <br /> -LEACHING LINE Cl No. & Length of lines r Total length/size t <br /> FILTER BED. ❑ Distance to nearest: Well Foundation Property Line a i` <br /> SEEPAGE PITS 11 Depth } Size f Number - <br /> SUMPSyAr LI" Distance to nearest: -q.Well Foundation Property Line 1 <br /> . <br /> DISPOSAL,PONDS ❑ <br /> •� 1 <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, an _ <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, 1 shall not �F <br /> employ any person in such manner as to become subjedt to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> f certifies the following: "I certify tha in the performance of the work for which this permit is issued, I shall empioy persons subject to workman's_ compensa- <br /> tion laws of Ca' rnla." ' <br /> he a nt t call fo all uirsd inspe tions. Complete drawing o wase fide. _. <br /> Sig d Title: i -- Date: - <br /> ,� �TZ}�RARTMENT USE ONLY r� <br /> Application Accepted by Date f a�3�� Area �,or <br /> Pit or Grout Inspection by Date Final Inspection by T�� P Date <br /> Additional Comments: <br /> Applicant -.Return all copies to: San Joaquin County,Publie .Health Services <br /> Environmental Health Permit/Services yt]� <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201lQ� <br /> FEE AMOUNT DUE AMOUNT REMITTED CK-* RECEIVED BY DATE PERMIT'NO, <br /> INFO CAH <br /> + EN 13-24 IREV.r/R5rWi <br /> EN 14.26 D o •o v/'� <br />