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APPLICATION )t/,g yewntd-t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ory <br /> ENVIRONMENTAL HEALTH DIVISION "—`- <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> _pBRMJ_J.. EXPIRES 1 YEAR FRPM PATE 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 /> Lot Sire/Acreage <br /> �ob Address Cit <br /> wnar's Nam -f Address Lrl1. 0�� `'— -� — Phone <br /> yaw <br /> L10 8:pm <br /> j Contiat:tor <br /> _ Address. License No. Phone <br /> I f� TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT f"1 DESTRUCTION Cl Out of Service Well. Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (I Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing_, _ Specifications <br /> I'I Public Cl Other n Delta Depth of-Grout Seal Type of Grout �[ <br /> I I Irrigation --._ Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done L7 Type of Pump H.P. _ State Work Done _ <br /> Well Destruction ❑ Weif Diameter "'Sealing Material i Depth <br /> Depth Filler Materia <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDiTIO DESTRUCTION i o septic system permitted if public sewer is <br /> ailable within 2 .fw,i <br /> Insttaaltgti ill serve: Residence— Commercial — Other <br /> Number of living urn . ,_ Number of bedrooms Y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capac' No. Compartments <br /> PK0. TREATMENT PLT. ❑ - Method of Disposal <br /> Distance to nearest: Well Founds Property Line <br /> LEACHING LINE 0 No, &�ae,i <br /> Ii Total long <br /> FILTER BED Cl Distaell Foundation Property Line <br /> SEEPAGi PITS I Depth Size Number <br /> SUMPS LI Distance to neatest: Well Foundation. Property Line <br /> DIS AL PONDS 0 <br /> 1 horeby 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; '4 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:."t comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion iswe.of lifornls," <br /> The appli a , call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: 6B .,.- ---- Date: <br /> FO EPARTMENT USE ONLY C� <br /> Application Accepted by Date / _r Area �`` <br /> Pit or trout Inspection by ata Final Inspection by 6141A Data <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 ox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNY REMITTED C K 11 E5 <br /> INFO SI ED BY O TE PERMiT'NO. <br /> /J /y <br /> EH 14.20 <br />