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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 /> y (Complete in Triplicate) <br /> Application in hereby made to San 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 No. 5L9 and 1862 and tie Rules and R/gulations of San <br /> Joaquin County Public Health Services. /"-yo <br /> Job Address ' N{ !, �-'I hl I c City C Q x Lot Size/Acreage rt"-,ti 3L <br /> Owner's NameAddress Ph <br /> g�� r'' + one }3 42-1 06 <br /> Contractor m[,'Lrc -5 Ot ? Address 4rAi) License hlo�3�6/ Phone 3 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well C] <br /> PUMP INSTALLATION �j SYSTEM REPAIR Ll OTHER ❑ Monitoring Well L� <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 /> Cf Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r-1 Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> I'l Public f-1 Other f1 Delta Depth of Grout Seal Type of Grout <br /> I Ir;tgalton _Approx. Depth I Eastern S rf ca Still Installed by <br /> Repair Work Done U Type of Pump ^ H.P. � State Work Done <br /> Material t Depth MateyU" t r <br /> Well Destruction ❑ Well Diameter Sealing A v- <br /> Depth v Filler Material i Depth }/ <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weir Founaatson Property Line <br /> r <br /> SEEPAGE PITS [ I Depth Size Number r� <br /> SUMPS LI Distance to nearest: Well Foundation Property Line \ <br /> DISPOSAL PONDS ❑ \ <br /> I hereby certify that I have prepared this appiica.F. nand that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin <br /> Home owner or licensed agent'ssignature>ertdies the following: "4 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 compent f <br /> tion laws of California." \ <br /> The applicant must cal for sll required inspections. Complete drawing on revs( side. <br /> Signed X - Title: DateY9 __ :f 7 C <br /> �PNT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by 'Z � - Data G <br /> 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 /> ZtNFO A OUNT DUE AMOUNT REMITTED OCCAS R EIVED BY D TE PERMI f N0. <br /> EH 13-24 <br /> EH 14.20 / <br />