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i APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES n <br /> ENVIRONMENTAL HEALTH DIVISION f J <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> I application 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 <br /> Services. }}� J✓ <br /> Job Address C j„, <br /> ..] f� LL�Qi City `J 1Ut�i`- Lot Size/Acreage T2 )( f 66 SSdoZv <br /> 414 <br /> or'sName ,neL f. Address 7,203 �� i'pt� ��m�';hone coq 3 <br /> �wn <br /> � /j���f 4Saa6 <br /> V Contractor e��� " - Address 2C3 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _—_FOUNDATION AGRICULTVREW4L_ pTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public t (:1 Other n Delta Depth of Grout Seal Type of Grout <br /> 11 lriigation _Approx, Depth ( 1 Eastern Surface Seal Installed by <br /> Repair Work Done� 0 Type of Pump H.P. _ __ State Work Done _ <br /> Well Destruction ❑ Well Diameter sealing Materiel k II th <br /> f Depth Filler A Depth <br /> i <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION f-I°:REPAIR! DO dON-IF}.�DESTRUGTION�CI dNo•se f system permitted if public sewer is ' <br /> :ater <br /> Wllflin�.feet.) <br /> Instal will serve: Residence Gorttmercral _ Other <br /> � I <br /> i Number of livin ts: Number of_bedrooms <br /> Character of soil to a de f 3 feet: ' table depth <br /> SEPTIC TANK ❑ Type Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: oundetian Property Line <br /> LEACHING LINE ❑ No. iii Lengtfiof Ii Total length/size <br /> ( FILTER BED ❑ Distance crest: Well Foundation Property Line <br /> SEEPAGE PITS I;; _Depth Size��- _ Number <br /> ' SUMPS it Distance to nearest: Well Foundation Property Line <br /> i. <br /> DISPO PONDS ❑ <br /> efeby 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 shell 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 ust call for all required inspections. Complete drawing on reverse side. = -5 <br /> tl f <br /> ✓$igned A Title: gate: <br /> F R PARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joa in County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaqui Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CK RECEIVED BYATE PERMIT NO. <br /> INFO <br /> l r EM 13.24 VtEv.I/n51 ./' q+ <br /> EK 14-26CGGV/// <br />