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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 0 BOX 2009, STOCKTON, CA 95201 <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 described. This <br /> application is made in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of SanJoaquin County Public Health Services. d, <br /> City <br /> Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> (l J�^S OV Vim- Addressl�+t Phone <br /> _�--� .l{' <br /> Contractor <br /> dress `S CA,- c.c.??/ &2 1 Phone <br /> NEW WELL ❑ WELL REPLAC MEN DESTRUCTION ❑ Out of Service well Cl <br /> TYPE OF WELL/PUMP: <br /> PUMP INS ELATION ❑ SYST M REPAIR L <br /> OT R G fdonitori Nell 0 <br /> SEWER LINES `� DISPOSAL FL PROP- LINE <br /> DISTANCE TO NEAREST: SEPTIC T -�� <br /> FOUNDATION <br /> WEL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> G Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Egxcav tion Specifications <br /> Domestic/Private Grave! Pack ❑ Tracy Type of Casin I <br /> Type of Gro _J <br /> A— <br /> FI Public (:1 Other Cl Delta Depth of Grout Seal � <br /> ��w <br /> I I Irrigation �.APprox. Depth �LEastarn Surface Seat installed by <br /> H.P. a5jiate a <br /> Repair Work Done U Type of Pump Sealing Material t+ Depth J.� <br /> We" Destruction CA. Well DiameterV Filler lfaterial <br /> Depth ; i Depth ' <br /> c system <br /> o sit <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ; DESTRUCTION 1 1 iiNeilabletlw thin 200 permitted it public sower is <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: . Number of bedrooms Water table depth <br /> Character of soiito a depth of 3 feet: k, <br /> SEPTIC TANK. ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> I1 Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE C1 No. & Length of linea Total length/sire- <br /> FILTER BED D Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS Ll Distance to nearest: Well Foundation - Property Line <br /> DISPOSAL PONDS Q <br /> I hereby certify that I have prepared Ihis 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 ticensed agent's signature certifies the following. "I certify that in the performance of the work for which this perrrt 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 of sub-contracting signature <br /> certifies the following: "I ca ify that in the performance of the work for which this permit its issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Caltforn! <br /> The appli atI r all requ d ins tions. Complete drawing on rVarse side <br /> Title: Date: <br /> Signed X _ <br /> !i FOR DEPARTMENT USE LY �r J) •� <br /> ate .,Area <br /> Appkfcation Accepted by <br /> DG <br /> Pit or Grout Inspection by Date �- 2Final Inspection by Data �- <br /> Additional Comments: �°� <br /> Applicant - Return all copies to: San Joaquin County Public Health cervicesw'�'_� <br /> 445 N San <br /> Health permit/Services <br /> ces 1 fF����, <br /> 445 N San Joaquin, P O Box 20D9, Stkn, CA 95201 � d� � �� <br /> FEE AMOUNT D E AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> '2 <br /> EM 13-24(Rev.I/AS,' W <br /> y EM 14.76 M/ (/V <br /> L <br />