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APPLICATION �� iq <br /> � S"00/ <br /> ,�Q 0/ 3 � <br /> SAN JOAQUIN COUNTY PUBLIC HEALT DIVI V ES v <br /> 445 <br /> ENVIRONMENTAL <br /> SAN�NO�AQN IN, HONE C 209) .. `" U �� �j <br /> i + P O BOX 2009, STOCKTON, CA # <br /> �' E 1 FROM E <br /> (Complete in Triplicat ,3 -- <br /> i Application is hereby made to &w 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 Po. 549 and 1$62 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> I <br /> I� Job Andress City &:OkAl Lot site/Acreage '4J4414C.-- _ <br /> Owner's Name (.Address �R!;ei Phone <br /> Conlratioi Address_ r�U �- 4944264!! License No. Phone <br /> TYPE OF WELL)PUMP; NEW WELL 10 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - -I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f Cl industrial O Open Bottom 0 Manteca Dia. of Wall Excevation Dia. of Well Casing <br /> 171 Domestic/Private ❑ Gravel Pack 0 Tracy Typo of Casing_ Specifications <br /> VI PubNc n Other 11 Delta Depth of Grout Seal Type of Grout <br /> t I I Irrigation ^ Approx. Depth I I Eastern Surface Seal Installed by ' <br /> I Rapak Work Done U Type of Pump H.P. .-- State Work Done, d1 <br /> W90 Destruction ❑ well Diameter Sealing Material E Depth <br /> Depsh Filler Material i Depth <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION (No septic stem permitted i! <br /> 1 P Y ptrbfic aewar is /t <br /> available within ZOO feat.l <br /> Installation will serve: Residence— Commercial— Other <br /> t^ Number of living units. Number of bedrooms <br /> Character at nail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TytaeiMf <br /> 9 Capacity Na. Compartlnente <br />' PKG. TREATMENT PLT,❑ Method of Disposal <br />` Distance to nearest: Well Foundation Propeny Line <br /> 1! <br /> J <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Properly Line <br /> " SEEPAGE PITS 11 Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> F; I hereby Cbmily shat I have prepared this application and that the wont will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and ►egulalions of the San Joaquin County <br /> home owner or licensed agents pignaiure certifies the following: "1 certify that in the Perlormance 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 compartsalion laws of Califomis."Contraatar's hiring or sub-conuacting signature <br /> Fr, Certifies the foaming:-I comity that in the performance of the work for Which this Permit is issued, t m <br /> shall employ persona subject to workmen's copensa- <br /> tion Iavre of CaNfornie." <br /> The applicant must reap for all required inspections. Complete drawing on reverse side. I <br /> SigrwdK__ �i 7%� .f��;, r/ Title: <br /> Date:FOR DEPARTMENT USE ONLY <br /> Apptkatian Acespted by Oats 3 <br /> Area <br /> f } pk or Grout ittspectbn by Date— Final Inspection by 6 Date <br /> lIII 111 � <br /> Addititme Comnionts: � �� .r 1r f4k�,t& <br /> MApplicant - Return all copies to: San Joaquin County Public Health Services <br /> ,,S Environmental Health Permit/Services <br /> -i <br /> � A 445 N San Joaquin, P 0 Box 2009, Stltn, GA 95201 <br /> ;E1] <br /> FEE AMOUNT OtlE AMOLfNT REMfTTED CASH RECEIYfp BY pall? PERMT—rj fo.FL <br /> EM 13-11IRFY.risnl � tb op <br /> ! f ✓ /,J ti t/ 1.3 <br /> i <br />