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APPLICATION <br /> -'-I S JOA UIN COUNTY PUB . � r, <br /> Q LIC HEALTH ,fSER1RS <br /> ENVIRONMENTAL HEALTH D I V I S ION <br /> Pn <br /> 445 N SAN JOAQUIN, PHONE (209)468 Q 2. <br /> P O BOX 2009, STOCKTON, CA 9 2a --`�--- <br /> F <br /> PERMIT EXPIRES 1 YEAR FROM DATEIISSUED <br /> (Complete in Triplicate)" <br /> Application is hereby made.to Sa.n'Joaquin County for a permit to construct and/or install the vorkherein descri s <br /> application is made in cetapliance with San Joaquin County Ordinance No, 5t9 said 1$62 and the Rules and Regulations of San <br /> � Joaquin County Public Health Services. <br /> I <br /> Job Address City Lot Size/Acreage <br /> Owner's Name _ Address ori Phone <br /> ` Contractor Address �ilVo.a ��,`T`%' 'Phone <br /> icense <br /> TYPE OF WELL/PUMP: NEW WELL 0- WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well U' <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 /> 0 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation � 30' 9f Well Casing <br /> f <br /> 171 Domestic/Private Cl Grabet Pack L7 Tracy Type T g �1 ibrws B►� <br /> of�Casin I <br /> i"1 Public la Other n Delta Depth o4 Grout Seal t Iout \A, <br /> I I Irrigation Approx. Depth 1 1 Eastern Surface SealInstalled by S _y,1 <br /> _ Repair Work Done 0 Type of Pump H.P. r Q(� <br /> t Weil Destruction 0 Well Diameter Sealing Materiel L Depth _���f .A OIIn,_ <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR%ADDITION X DESTRUCTION l I INo septic s stem <br /> y public sewer is <br /> • t available within 200 feet.) +Y <br /> Installation will serve:' Residence—P-11Commercial_ Other <br /> t-° Number of living units:.�� Number of bedrooms <br /> Character of soil to depth of 3 feet: Water table depth \ <br /> -• �-� ._, <br /> SEPTIC TANK ❑ Type/Mfg . '� p,{ `7rL Capacity No. Compartments <br /> PKC. TREATMENT PLT, ❑ Ma, r Method of Disposal <br /> ' Distance to nearest. Well 15�2 � Foundation 0 Property Line_Csve"e— <br /> LEACHING LINE ( No.,& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well' ;Foundation y� Property Line <br /> SEEPAGE PITS I I Da th �� / <br /> P Size -f Z-0 Number <br /> SUMPS X Distance to nearest: WeII fLr 1 r Foundation.Property Line- <br /> DISPOSAL PONDS ❑ i. <br /> 1 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 /> LLL 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 California." <br /> The applicant must call for II r uired inspections. Complete drawing on reverse side. <br /> k <br /> Sig ned .�k - _ <br /> Title':;: �' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z- O Q Area <br /> F <br /> Pit or Grout Inspection by Date _Final Inspection by Date <br /> e 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 fIEMITTED <br /> INFO H CEIVEA.BY DATE PERINIT'NO. <br />