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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 SOX 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 3.862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ✓Job Address .SJ Goma. City .S'�� aNLot Size/Acreage <br /> ✓owner's Name L2 C-« Ai2 Address 5'5Phone <br /> Contractor-_ 1 __Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ .WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER ❑ Monitoring Well LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP UNE <br /> Ir <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C) Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ('1 Public f-1 Other f-1 Delta r Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> r <br /> Repair Work Done 0 Type of Pump. H.P. State Work Done <br /> Well Destruction ❑ Well Diameterf Sealing Material Depth <br /> r <br /> Depth Filler!Material i Depth <br /> YPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION t I DESTRUCTION I (No septic system permitted if publi er is <br /> available within 200 feet.) <br /> Installation rve: Residence Commercial Other <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 Water table depth <br /> L SEPTIC TANK ❑ Type/Mfg Capacity No. Compartrnents <br /> PKG. TREATMENT PLT. ❑ + Method of Disposal <br /> Distance to nearest: Well undation Property Line <br /> t 4_ <br /> LEACHING LINE ❑ No. 8 Length of linetai length/size <br /> FILTER BED L1 Distance to est: Well Foundation arty Line <br /> SEEPAGE PITSDepth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPO 'NDS ❑ <br /> reby 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 Joaquini County 1�f. <br /> Horne owner of licensed agent's signature certifies the following: 1 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for ail required inspections. Complete drawing on reverse side. <br /> Signed X tVutCl2 C T Title: Date: q-4-3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by l Date Area <br /> Pit or Grout Inspection by r Date ction by <br /> nal Inspe - 4✓ c- Date <br /> Additional Comments: <br /> 1 - <br /> Applicant - Return alllcopies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMO NT AEMITTED CA CEIVED E PE11 RMIT'NO. <br /> . EH 13.24 tt1EY. SD <br /> fH 14-2e - CJS <br />