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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 vork herein described. <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of <br /> Joaquin County Public Healthl} Services. n,� icy <br /> Job Address �' `� 00�(a& S�Q�� City �A 9 Lot Size/Acreage ^- 0 �� <br /> Owner's Name P meet C av- �!2,i Address 4 0 D � ' �Aaln S�. , 4�vt F Phone <br /> OD� (1011 ),94b-631T <br /> Q CJ S 290 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL Zi WELL REPLACEMENT i DESTRUCTION G Out of Service Well <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ 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 O Manteca Dia. of Well Excavation - � 1 S Dia. of Well Casing <br /> f 1 Domestic/Private ravel Pack O Tracy Type of Casing- e- SCA-_40 Spocdicatiol.. <br /> 11 Public C1 Other 100fe,"K CI Delta Depth of Grout°Seal Typo of GroutCiAWy - \ <br /> I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter !21%"s Sealing Material i Depth �M�( Ay 1-4-27 <br /> Depth d-) ,± Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i�, REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted d public Sawa, i <br /> available within 200 feot.l <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE G No. 6 Length of lines Total lengcn/size <br /> FILTER BED l-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lino <br /> DISPOSAL PONDS O <br /> 1 hereby candy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state ba. <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 msuod. I sh <br /> employ any person in such manner as to become subject to workmen's compensation laws of California. . Contractor's hiring or subcontracting sic <br /> conifies the following: "I conify that in the performance of the work for which this permit is issued. 1 shall employ persons subject to workman's corn <br /> tion laws of California." <br /> The applin must call for all required inspections. Complete drawing on reElde. <br /> Signed x Title: �eCk- �AO-Ir�e4 Date: �113 it <br /> P P t RD/ FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date C Area <br /> Pit or GroutAnspection by Data Final Inspection by Data <br /> Additional Comments:l ��6 gi5 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ply <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUN�TI�D/tJIE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. <br /> EM 13-24 111Ev.i/itsi [� l ' O [ L �/C�Q l Ci <br /> EM t1.27 <br /> 01 /7 <br />