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i <br /> APPLICATION SR 4 <br /> Tt � <br /> SAN JOAQU I N COUNTY PUBLIC HEALTH $W��C S <br /> ENVIRONMENTAL HEALTH DIVISI �{{ '7 <br /> 445 N SAN JOAQUIN, PHONE (209)4 Wt*W <br /> P 4 BOX 2009, STOCKTON, CA 9 <br /> P I IBES 1 Y RO E _ S7L ! L <br /> (Complete in Triplicate) <br /> Application is hereby Wade to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> applice,tioa 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 I. t <br /> 5 �� � �p { •� /� A,0�. .-- Lot ot Biz./Acreage <br /> Job Address -36 <br /> ..3� Phone <br /> Owner's Nam Address <br /> L ��r r Q License Na a Phone <br /> Contracts �^ (�SAressWell 0 <br /> TYPE OF WELL/PUMP: NEW WELL LJ SYSTEM <br /> REPLACEMENT Cl DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION f SYSTEM REPAIR <br /> OTHER ❑ Monitoring <br /> -DISPOSAL�FL•D:-- �-• '-PROP.'LINE <br /> t -DISTANCE-Td344EAREST:='SEPTAG=;+4iYK'- ' - AGRICULTURE WELL — OTHER WELL PITS/SUMPS _ <br /> FOUNDATION <br /> INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia- of <br /> Type of Casing_ Specifications <br /> 14 Domestic/Private L1 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> i'l Public El Other t 1 Delta <br /> I i irrigation Approx. Death I Eastern urface Sea! Installed by <br /> �� H P. ��7- w State Work Done <br /> Repair Work Done U Type of Pump ge4ijhg`IrleTterial & Depth <br /> Weil.Destruction s❑ Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION i I DESTRUCTION I I alvo ailable sepilc systithinem <br /> permitted if public sewer is <br /> Installation will serve' Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth \ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> I <br /> LEACHING LINE Cl No. E Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wed Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sias <br /> Number <br /> �- SUMRS=-. ... •�� �, L1-,I?rotance to nearest: .Well yFo�undatign� _ _- _ :Prop" Line <br /> DISPOSAL PONDS ❑ <br /> work will be done in accordance with San Joaquin County ordinances, state laws, and <br /> I hereby certify that I have prepared this application and-that the <br /> rules and reputations 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." Contractor's hiring or subcontracting signature <br /> certifies the person <br /> folliciinn:"I certify that s o come sante°f the work for which this permit is issued.I shad employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cad fo Il required inspections- Complete drawing on reverse side. <br /> r <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ON / <br /> Date r Area <br /> Application Accepted by 4141 <br /> 3 <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Data <br /> Additional Comments: <br /> Applit - Return all copies to: San Joaquin County Public health cervices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVER BY GATE fPERM11 NO. <br /> GASH RECEIVED <br /> j <br /> � EN 1344(REV.I i n sr -. <br /> EH 16-* <br />