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40 r <br /> r <br /> APPLICATION <br /> SR # - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV T D # G� <br /> ENVIRONMENTAL HEALTH DIVISION II <br /> 445 N SAN JOAQUIN, PHONE(209)469-3420 I f"� <br /> P O BOX 388,STOCKTON, CA 95201-0388 , t <br /> PERMIT EXPIRES 1 YEAR FROM DATE I SUED# I <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 application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address _'2L/- City eel W_ Lot Size/Acreage <br /> Owner's Namee R� * �1 ►� �✓� '�,� Address �� % r �W�/ C G h%4 I��ftbone ( — <br /> � <br /> Contractor ^ ( f / Address f. /"/ ✓ License No Phone z- <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT FI DESTRUCTION Cl Out of Service well 0 <br /> PUMP INSTALLATION ,C / SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL Z_-1Z7 PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C; Industrial O Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing \ <br /> t6"omesuc/Private ,Gravel Pack ❑ Tracy Type of Casing_ �� Specifications <br /> I'1 Public I 1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I i Irngauon 3uL Approx. Depth I I Eastern Surface Seal Installed by f171i LLQ l /rte <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction C Well Diameter Sealing Material i Depth �C <br /> Depth Filler Material i Depth \�1` <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sower 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 C Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal G <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. b Length of lines Total length/size <br /> FILTER BED C Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ) Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 applican must call for all requir inspections. Complete drawing on averse sid . <br /> k �1q <br /> Signed X I. L / ' I.4f_ Title: H / <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by a Date -7 Area I <br /> Pit or Grout Inspection by ��� ' pate 7�(�/�`1 Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Healt ervices 141 <br /> Environmental Health Permit/Services <br /> (� 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 <br /> T �D <br /> ` INF <br /> E AMOUNT DUE AMOUNT REMITTED K H RECEIVED By DATE PERMIT'NO. <br /> EN U•24(REV.mer U r I lV `��'/�� ✓VJl a <br /> EN 1426 <br />