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APPLICATION ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IN <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 I <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> M <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I <br /> (Complete in Triplicate) I! <br /> It <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This t <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulationsliof San <br /> Joaquin County Public Health Services. k <br /> Job Address W/S Airport Way, 660 ' N Zepher Ctity Stockton Lot Size/Acreage l <br /> 8625 Eldercreek Road II <br /> B 0 E Address Phone 916/381-Owner's NameSacramento, _ <br /> Contractor Clark Well, Ing,__Addres,s 2024 R Cha rtLrWA]r License No. 371560 . Phone 4 6 2- <br /> 7 67 <br /> TYPE OF WELL/PUMP. NEW WELL 3 i WELL REPLACEMENT CI DESTRUCTION AfDut of Service Well ❑ O <br /> PUMP INSTALLATION s 5Y.STEM REPAIR'D OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD." PROP.-LINE <br /> HER WELL <br /> FOUNDATION AGRICULTURE WELL OTPITS/SUMPS I'I <br /> WE <br /> INTENDED USE .i TYPE OF WELL PROBLEM AREA , CONSTRUCTION SPECIFICATIONS <br /> j� <br /> L) Industrial It Open Bottom (.Manteca .4 .Dia. of Well Excavation = Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack L)',Tracy ; Type of Casing_ s Specifications ; <br /> I I <br /> FI Public [-1"Other Depth of Grout Seal Type of-Grout <br /> I I IrriOaupn Approx. Depth I I:Eastern Suifaeg_Sea1 Installed by <br /> Repair Work Done ❑ Type of Pump Ii.P,4 t r` r State Work Done <br /> (Vo Sealing HateA4.1N"l; Depth + t <br /> Well Destruction © Well Diameter # f 4, ��0:t I- m <br /> Depth St 1`'iller Materialk& Uepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION It I INo septic system permit-RA if public sewer;is <br /> 4 available within 200 feet.I <br /> Installation will serve: Residence— Commercial— ,Oiher <br /> Number of living units: Number of bedrooms s I� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> w <br /> Distance to nearest: j Well " Foundation Property Line <br /> l" <br /> LEACHING LINE ❑ No. & Length of lines Total length/size i <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line I <br /> 3 <br /> SEEPAGE PITS 11 Depth t Size - �' + " Number II <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS o <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, and <br /> rules and reg tions of the San Joaquin County i <br /> Home owner.o Itnsed agent's signature certifies thq following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any r n iIn such nner as to me subjec to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies <br /> the <br /> f tl ing: "I ce i th in I e rmance the work for which this permit is issued, I shall employ persona subject to workman's Icompensa- <br /> tion Iowa of rnia." 1 <br /> The applic s c II or a it in c s. Co late drawing on IIs ease-sida' <br /> Signed X Title: 'Date: '1 �-✓.=" " <br /> F.17, ;"41P4RTME T,`USE ONLY <br /> Application Accepted lay r� •I,--- yam, 'b i. — - Date .�2 Area <br /> Pit or Grout Inspection by ' JMe F Final Inspection byO a - - 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, P O Box 2009, Stkn, CA 95201 I� <br /> { <br /> FEE AMOUNT DUE AMOUf T REMITYED N --EIVED BY DA PERMIT'N0. <br /> INFO <br /> � <br /> EH 13.14IIIEV.I/15) 0 <br /> EH t4•2 <br />