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r <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 4 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> Cr~Mn- Q�el PERMIT EXP I RE S 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 cozqpliance with San Joaquin County Ordinance No. 51+9 and 18 2 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I Job Address /46 � �• �� City�� Pt Size/Acreage <br /> Fj � . <br /> Owner's Name Address S JG. Phone <br /> 4 <br /> Contractor de Addresst:P /L Tc c,LKk License N3 G a O Pho <br /> "TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 171 Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR,,k OTHER O Monitoring well <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom k ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Cl Public �' (_) Other l 1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth t I Eastern " Suva Seal Installed by r <br /> Repair Work Done Type of Pump H.P. `L State Work Done ��- l`-'1V► <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION'I'.I DESTRUCTION I i iNo septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other Z <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. TREATMENT PLT.0 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r FILTER BED n Distance to nearest: Well Foundation Property Line <br /> F <br /> SEEPAGE PITS 11 Depth Size __ Number <br /> SUMPS L3 Distance to nearest: Welb Foundation Property Line <br /> C DISPOSAL PONDS o <br /> s <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 regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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:"' Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this-permit'is issued, I sol am—ploy persons subject to workman'.*compensa- <br /> tion laws,of California." <br /> The appliANust cal for all required "r ction Camp to drawing on rev r si e. <br /> r Signed ' Title w'� � Date: <br /> FOR DEPARTMENT USE ONLY `' a <br /> Application Accepted b <br /> PP P Y kcm1L ,., .__.. Date � 4`I �/ Area <br /> Pit or Grout Inspection by Date Final Inspection by f` Data QZ <br /> fi <br /> Additional Comments: <br /> 1l Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Sery ces '�l�` <br /> 111666 445 N San Joaquin 2009 Stkn, CA 95201FEE <br /> 1Nf0 MO/UNNT DUE AMOUNT REMITTEO CK RECEIVED 8Y DATE PERMIT'NO. pV` <br /> P . EH 13.24{REV.i i s� r(�jJgF ^/� <br /> EH t4-2a f J off t1 L <br />�- f <br />