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GCT 91992 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ' P 0 BOX 2009, STOCKTON, CA 95201 ` .'`,, <br /> PERMI E YEAR F E ISSUED <br /> �, :SAN <br /> t I �(complete in �f► a s) �. V1, y r:,/ rain, <br /> P 11/r. U;, . r zl <br /> ��>' ,. • r-•ref <br /> Application is hereby mode,to Seal Joaquin County for a-permtt to construct and/or Inatall the v�fil jirrre n;desc Spefl. This <br /> application is made in cotwlience,'with Sam Joaquin County Ordinance No. 549 and 1862 and the Rules LR'ogu]6LibnArof San <br /> Joaquin County Public Health Services. <br /> Job Address ROD �• City Lot Site/ reagc '� <br /> 1 <br /> 's Name • yCAddress <br /> _!' '�✓ � �� `�'°" •'`0; Phone i <br /> ,fn �( <br /> + ConUaclor Address�8 J4 1Z <br /> + 't r License No. —12 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ ' <br /> - Pt1MP INSTALLATION 0.. SYSTEM REPAIR ❑ .r _.OT EA ❑ Monitoring Well. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP.'LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑/Open Bottom CVManteca Dia. of Well Ex ion Dia. of Well Casing <br /> EI Domestic/Private Q�Gravel Pack ❑ Tracy Type of Casing f C7# Specifications,�� <br /> I'I Public 1"1 Other (-I Delta Depth of Grout Seal Type of Grouts-rm <br /> I I Irri otion —Approx.;Depth l I Eastern Surface Seal installed by E,2t _f ; <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameterr Sealing Material k Depth <br /> Depth Filler Material i Depth— <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I tNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence—� Commercial_. Other G <br /> Number of living unite: Number of bedrooms <br /> Character of soil to a depth of 3 feet:f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.IDy Method of Disposal <br /> Distance to nearest: Well Foundation -Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS 11 Depth �,• Siie_ ' ' Number <br /> SUMPS L l Distance to nearest: Well 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, an <br /> rules and regulations of the Sen 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 laws of California.—Contractors hiring or sub-contracting signature I <br /> canities the foNowing: "1 cenity that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's eompensa <br /> tion iaws of C rnia." <br /> The spp6i: t mu t call (or aN r irad in ons. Complete drawing on reverse side. <br /> Signed Title: ✓ /� 97 Date: v" D L <br /> FOR DEPARTMENT USE ONLY <br /> T Application Accepted by Date `� Z Area r q <br /> Pit or Grout Inspection by Date_ �/?L Final Inspection by Date ^! 2— <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services Z I <br /> I Environmental Health Permit/Services I <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REM"""IITTJTED CASH/ RECEIVED BY DATE � PERMII NO..- <br /> EK 1 -2 rREV.,i 41 <br /> EK 144.24 <br /> r <br /> FEE <br />