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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 5 CLQ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> mv <br /> PERMIT E%PIRES 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / �. <br /> Job Address `s City ZL � Lot Size/Acreage <br /> Owner's Name r. /✓ ddress / /fir �F� Phone C i <br /> Contractor � �_ S' Address-_-P � ���9 License No.JPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ <br /> *+ - R ---�. - aTHER-CMonitoring Well ❑ <br /> F PUMP INSTALLATION ❑�'�'"'-'""'�•"SYSTEM'REPAIC7 . Or - <br /> ,._.DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION' 'w—AGRICULTURE'WELL�OTHER WEL"L"`"'"S PITS/SUMPS, ..Mr <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi"k <br /> I <br /> Cl Industrial ❑ Open Bottom n Manteca Dia. of Well Excavation f Dia. of Well Casing <br /> t <br /> f7 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> I'I Public C1 Other n Delta Depth of Grout Seal I Type,of Grout*� <br /> I I Irrigation _ _,Approx. Depth I 1 Eastern Surface Seal Installed by ti <br /> aook <br /> Repair Work Done 0 Type of Pump H.P. State Work one ' <br /> Wall Destruction Well Diameter Sealing Material i Depth r /� �e� fl <br /> Depth Z Filler Material i Depth Ally <br /> —..s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I !No septic system permitted if pukiliic sewer is <br /> available within 200 feet-I A% <br /> Installation will serve: Residence T Commercial— Other' I { <br /> # <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth y <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments �. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f fl <br /> Distance to nearest: Well Foundation Property Lina - <br /> ! <br /> LEACHING LINE C#1 No. & Length of lines---- Total length/size i r I ,l` <br /> FILTER BED n 11 Distance to nearest: Well M Foundation Property Line <br /> SEEPAGE PITS I I pepth ; ` Size Number. # * ! <br /> SUMP LI Distnce,tojnearest: Well Foundation, Property Line #� <br /> Dl5FPOSAt.;PONDS ©: !- <br /> I hireby cenify'that I have prepared this-application and that the work will be done in-,accordance with San Joaquin.counfy ordinances stale laws,and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed,agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such-manner as fo become subieet to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the.vvork for which this permit is issued,.I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> F The applica must I gpletsed,i omdrawing on rev side, <br /> i <br /> Signed , Title: Date: <br /> JV <br /> 3y FOR DEPARTMENT USE O Y <br /> ` Application Accepted by t. Date f Area <br /> r . y <br /> � Pit or Grout Inspection by � " � � � ata .Final Inspection by Date <br /> k Additional Comments: 1 <br /> -- <br /> Applicant Return all copies to: San Joaquin County Public Health Services <br /> 'Environmental Health Permit/Services <br /> .445_•N•San Joaquin; ­P"O•Sox 2009,-Stkn-,(3A"95201"" '��r <br /> FF AMOUNT DtJE AMOUNZ REMITTED. CK ti '.3 ECENED BY DATE PERMIT NO. <br /> ♦, r <br /> J /y� <br /> . EH 17-24(REV.I/N 5Y ..r _ _ __ _- /-- �.�.. L <br /> EH SI-�a --- -T - - - -- - - - - <br />