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APPLICATION <br /> } RECEVE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MAY 1193 ," <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ENVIRONMENTAL HCALTH <br /> P O BOX 2009, STOCKTON, CA 95201 P RMIT/SERVIC0 <br /> E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sin <br /> Joaquin County Public Health Services. "9 <br /> ,y�� .I <br /> Job Address V{1►'L ' _- - '-CA City Lot Size/Acreage <br /> i <br /> Owner's Name Address a Phone <br /> Contract dre am R �e�- ( License NV__,02-__Phon � �T <br /> TYPE OF WELL/PUMP: :NEW WELL ❑ WELL REPLACEMENT C❑ DESTRUCTION ❑ Out of Service Well L1 (J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK +SEWER LINES DISPOSAL FLD. PROP. LINE " �q <br /> FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ilk INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 3i <br /> li �17�) Industrial ❑ Open Bottom C) Manteca _ Dia. of Well Excavation Dia. of Well Casing <br /> ) Domestic/Private ❑ Gravel Pack ❑ Tracy Typee of Casing_ Specifications iI <br /> I'1 Public f:1 Other I-1 Delta Depth oF,Grout Seal Type of Grout <br /> I I Irrigation —..Approx; Depth t I EasternSurface Seal Installed by 1i <br /> Repair Work Done jpw Type of Pump,► H.P.fi3� _ State Work Done �I <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> II Depth Filler Material & Depth <br /> s <br /> f' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I ]No 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 /> 1 Ii, <br /> Character of soil to a depth of 3 feet:_ _._- - Water table depth '! <br /> SEPTIC,TANK. ❑ Type/Mfg Capacity No. Compartments <br /> ,.PKG. TREATMENT PLT. ❑ t. Method of Disposal <br /> Distance,to nearest: Well Foundation Property Line �? <br /> i <br /> LEACHING LINE D No. & Length,of lines Total length/size II <br /> "' ' n <br /> FILTER BED [�` Distance-to`nearesr.- ' "NNeil � Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Dis[ancelto nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisIapplication 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: "I 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: "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 Californla." #I <br /> The applican for,ail req�yred inspections- Complete drawing on verse side. <br /> Signed X Title: _� . __ Date: _3 <br /> .Ii <br /> 3i <br /> FOR DEPARTMENT USE ONLY { / �1p� <br /> Application Accepted by , I, — Data Area_['L: L b flak <br /> Pit or Grout Inspection by ! Date Final Inspection by Date <br /> Additional Comments: <br /> l <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health permit/Services i! <br /> 445 N San�,Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE y V :I <br /> )NFO AMOUNT DUE AMOUNT <br /> ,�REMITTED //���CABH RECEIVED BY DATE PERMIT'ND. <br /> . EH 1 -21[REV.r i x SF � ,� [JV J <br /> EH 14•20 f f9l <br />