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rs r APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1 P 0 BOX 2009, STOC%TON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein describ6d% This <br /> application is made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address tit City / Lot Size/Acreage <br /> 1/7 <br /> Owner's Name �9+5� — Address T. G/� Phone <br /> /� Q /..�otrcr�s�isK- ,gLvv S/d`B�G �9 <br /> Contractor f o4c / +����' ' Address .+4�4 Af . C/� License No.Z �Z7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �ROP. <br /> ❑/Out of Service NellPUMP INSTALLATION C1SYSTEM REPAIR 0 OTHER Mo ori BellDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, Ll <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Z 3K Dia. of Weil Casing <br /> C.1 Domestic/Private Cl Gravel Pack7i ❑ Tracy Type of Casing.— Specifications <br /> I"1 Public 1-1 Other n Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation ._._..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P, ___— State Work Done , <br /> Well Destruction ❑ Well Diameter sealing Material Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No 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 D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property tine <br /> LEACHING LINE C1 No. & Length of lines Total length/sire <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 /> 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 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 m t call for all req red inspections. Complete drawing on reverse side. <br /> Signed Titie: T Date: 4Z <br /> FOR EP TMENT USE ONLY Ar <br /> Applic/ioncepted by Date Y_1, ~ Area 42' 4 <br /> J� <br /> Pit or Grout Inspection by Date Final Inspection by, Data <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AM <br /> INFO OU T REMITTED ASH RECEIVED 8Y DATE PERMIT'N0. <br /> . EH 1721tREV.tiKsi ne " GD / 73 -06 .�o <br /> EFS 14.20 "� <br />