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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 y� <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 i <br /> application is trade 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 Cityt Size/Acreage <br /> Owne('s NameAddress� �1�`7 �I`ice___ .tr sL2lyr L _ Phone <br /> Contractor � ' -p �'� Address License No.�� 6J Phone <br /> TYPE OF WELL! M NEW WELL C1 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> w <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications-- - — } <br /> I') Public. M Other Fl Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation Appfox. Deptk I I Eastern Surface Seal nstalled by <br /> Repair Work Done V Type of.Pump ts- N.P. L�� Sate r Da <br /> Well Destruction 0 Well-Diameter' Sealing Material Depth ! <br /> Depth Filler Material & Depth d <br /> CG+st i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.). <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: Water table depth "* <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG, TJEATMENT PLT, ❑ '. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED CI 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, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensad agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall no w <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signator <br /> certifies 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 mu call all required inspections. Complete drawing on reverse side. <br /> f � r <br /> Signed X�tTM t/3C�;.a Title:, 4zs�[� Data: ' <br /> 10PROEPARTMENT USE ONLY <br /> Application Accepted by Date 2 Area <br /> Pit or Grout Inspection by Date <br /> - Final Inspection bV 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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMPUNT REMITTED RECEIVED BY DATE PERM17'NO. <br /> FQ CASH <br /> . EN1 .2 IREV.+/ns� <br /> 4 1 <br /> rK 1.-2s YY <br />