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APPLICATION <br /> SAN 5"QUIN COUNTY PUBLIC HEALTH sdVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin Canty for a permit to construct and/or install the work herein described. This <br /> application is made in c=Vliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,c <br /> Job Address -3 �L© `' //r����T City - Lot Size/Acreage <br /> Owner's Name Itltn'A" A"' Address 5+ L 3 ONS ar� Phone <br /> ef 3.1-3 D <br /> g 4371 Contractor V w Address P "�31 /lA I LO��4"�Li nae No. a 7 6 Phone 116 6j/"�J6E <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well g <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ul'i/ DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /1!7-- Dia. of Well Casing <br /> Cl Domestic/Private ® Gravel Pack ❑ Tracy Type of CasingQ­e,!!&-_Z-10 A 1//G Specifications <br /> % <br /> I'1 Public C'I Other Cl r,Delta Depth of Grout Seal � * Type of Grout <br /> � t <br /> ✓'f >�,3 <br /> I I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by <br /> V} l��ei. <br /> Repair WorU Type of Pump A!A H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material Z Depth <br /> Depth p/6 Filler Material i Depth A/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) CID <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 t IE <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation j?Jope�,y�l r_NT-- <br /> LEACHING LINE ❑ No. & Length of lines Total I & �yyyy��CC <br /> FILTER BED ❑ Distance to nearest; Well Foundation __1•" ely InJ998 _ <br /> SEEPAGE PITS II Depth Size <br /> t <br /> SUMPS LI Distance to nearest: Well Foundation_. IAry o&L4�� <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."Cot+nacw►'rhiiM-m.sutscontracting signature <br /> certifies the following: "1 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 must call for all required inspections. Complete drawing on reverse sidle. <br /> Signed XyU' _V_ Title: �"-:r �-'�'�� �c Date: / 0`-2-L23 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date 2� Final Inspection by Date <br /> Additional Comments: /�rGW t�(J1.fi <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> �5(�/ <br /> CK S <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> INFO / <br /> . EM/7.24 IAEV.,,h 51 �`j/ �Q 03 o -27- OD138o <br /> EM 1620 -f <br />