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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH`!3�RVICES p <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 . <br /> PERMIT MIRES 1. YEAR ,FROM DATE ISSUE£} , <br /> (Complete in Triplicate) <br /> Application is hereby msde.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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address ,� Gd2 � ,ifr tk_A-AAJ JR"b City A P.n�' _ Lot Size/Acreage <br /> Owner's Name �f /!V(af P•�VW i— Address _Stir iCi Phone <br /> Contractor 7 n 4. 1- '".1 --Address , 7Aj, License No.#_2nfi2-2t. Phone l = ?l <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out or Service Well 5 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <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 /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F1 Domestic/Private 0 Gravel Pack E Tracy Type of Casing- Specifications <br /> i'I Public EI Other f"I Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done (J Type of Pump H.P. State Work Done _ <br /> Well Destruction © Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATION I I REPAiRIADOITIt?N DiSTRUCTION I I (No septic system permitted if public newer is <br /> available within 2W feet-1 <br /> installation will serve: Residence_.,. Commercial e-,r Other j� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 41—ehm Water table depth <br /> SEPTIC TANK i3 Type/Mfg Le Capacity 1 -00 No. Compartments <br /> PKG. TREATMENT PLT:0 Method of Disposal <br /> Distance to nearest: Well &'„IA Foundation f'Q ` Property Line <br /> LEACHING LiNE No. & Length of lines 7- - Z CIO t Total Length/size ` <br /> FILTER BED n Distance to nearest: Wait 6,64— Foundation 3c.7' Property Line 7--"' <br /> SEEPAGE PITS I I Depth I? r Sire 2.X 12� Number 7- <br /> SUMPS <br /> SUMPS X Distance to nearest: Well !4M Foundation /00' Property Line / 5'' <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 /> Horne owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued, {'shall not <br /> employ any person in such manner as to hecome'subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following "I certify that in the performanceofthe work for which this permit is issued,i shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X . ++s '' z+ Title: &29& pate: <br /> FOR DEPARTMENT USE ONLY <br /> AD <br /> f t- . <br /> Application Accepted by tt `X t?l Date tt Area <br /> Pit or Grout Inspection by Date Ficial Inspect#on by 4 Data � 11 Y <br /> Additlonal 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 Sox 2409, Stkn, CA 95201 <br /> owIFEE NFO AMOUNT DUE AMOUNT REMITTED CK te RECEIVED BY DATE PERMi7'NO. <br /> . ELS 73-241#tt:V:.41n5r <br /> EN 74.20 <br />