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APPLICATION <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �/�/ <br /> Job Address V�`"r "KA City �Dl of Size/Acreage <br /> ,,��]] ����JJ{� / �� LUPI Cdl•Gi s , <br /> Owner's Name�r4`7� +� Address <br /> 1 <br /> —Cantratt Flddres 4'CO�f License N�aSl�r�t� Phon <br />`....�._,. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Cl; ' <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES ' `—R` �1SPO5AL FLD. PROP. LINE- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE. ::- u TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I'] Do em sticlPrivate ❑ Gravel Pack L7 Tracy^-^- Type-of-Casing-* Specifications <br /> I'I Public la Other f-3 Delta Depth,,ol Grout Seal— Type of Grout <br /> I I Irrigation �` ' — Approxi Depth I I Eastern Surface'Seal Installed by <br /> Repair Work Done 01,Typs of Pump H.P. - State Work Done T <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth-- <br /> Depth- Filler Material & Depth R <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION -tNo septic system permitted if ibffi�­sewsr is <br /> vailable within 200 feet. <br /> 'Installation will serve: Residence k Commercial_,.""_ Other •-r--r�rr )�� �� <br /> : Number of Living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:i Water table depth <br /> SEPTIC TANK ❑ Type/Mfg .Capa No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Len�nearev. <br /> Total length/sire <br /> t <br /> FILTER BED n Distan Well Foundation Property Line .4, ; <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DlIt SAL PONDS ❑ <br /> I hereby certify that 1 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 person in such manner as to become subject to workman's compensation taws 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 California." <br /> The applicant musl call for all r® ire ins p- ions, CWpI9A drawing on r se side. <br /> SignTitle: ___ Date. <br /> FOR DEPARTMENT USE ONLY y T <br /> Application Accepted by Date Are <br /> Pit or Grout Inspection by Hate Final Inspection by r Date - 2 <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'N0. <br /> INFO SH <br /> EH 13-24 IREV.i H 51 <br /> EH 14.20 L <br />