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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. CV 7�t 2- 1,0 <br /> Job Address 4.54 City-- Lot Size/Acreage <br /> Owner'aName Address 3 , Phone - �L1� <br /> ' r7— �r V q f�� C' <br /> Contractor Address r�'e' Lice e fV Phoneme 7 <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well L❑-. <br /> PUMP INSTALLATION 7 SYSTEM REPAI OTHER D Monitoring'Well C7 <br /> DISTANCE TO <br /> 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 /> F) Industrialpen Bottom EIManteca Dia. of Well Excavation_ Die. i Well Casing <br /> (-1 Domestic/Private ❑ Gravel Pack7 0 Tracy ,Type of Casing._ h - Specifications <br /> VI Public fa Other 11 Delta Depth of Grout Seal Type of Grout <br /> "anon — Approx. Depth I I Eastern Surface Sew Installed by <br /> /Repair Work Done L] Type of Pump H.P, _ State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth � <br /> Depth Filler !Material i 'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION-C-1. DESTRUCTION.1_i.INo septic system permitted it public sewer is <br /> available w in 200 lest.i <br /> Installation will serve: Residence— Commercial% Other <br /> A <br /> Number of living units: Number of bedrooms M <br /> Character of soil to s depth of 3 feet: Water table depth <br /> s � <br /> SEPTIC TANK s ❑ Type/Mfg pacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nesrest: Well Foundation Property Lie <br /> f , <br /> LEACHING LINE Cl No. & Length of lin Total length/size <br /> FILTER BED 1 ❑ Distance to n st: Well Foundation Property Line f. <br /> SEEPAGE PITS' I I De Size Number <br /> SUMPS LI istance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartilies the f o in : "I certity that in the performance of the work for which this permit is issued, (shall employ persons subject to workman's compensa- <br /> tion <br /> E <br /> laws ofSull <br /> " <br /> The ;fa— <br /> or ire ' pactions. Complete drawing on reverse lsidade. <br /> Date:Title:Sign <br /> I1 Z? <br /> .41 <br /> "OkK <br /> DE ARTMENT USE ONLY �{ 2 <br /> Application Accepted by Date. 1-013 J Area C) Lt <br /> [� N <br /> Pit orro t Inspection by Date Final inspection by Date <br /> 611)t Inspection <br /> s <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED t RECEIVED BY TE PERMIT'NO. <br /> INFO <br /> rEH13-24tREw.r/H51LAff,, <br /> EM 14.Ie l <br />