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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ;445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> �\ I 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 coapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules a.nd Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address a 2 Of /7 �T Vg- <br /> City SC 4t� L�Lot Size%Acreage J� i <br /> Owner's Name 41/CAl I C'A? AA Address -3 -lZr.44,—� Phone S <br /> Contractor yalw ir/l Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION D Out of Service Well 0 <br /> PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ; <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing , <br /> Il Domestic/Private ❑ Gravel Pack+ n Tracy Type of Casing_ Specifications <br /> r I'1 Public Cl Other y 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. . State Work Done <br /> Well Destruction 0 Weil Diameter Sealing Material & DepthINIZ <br /> Depth ; Filler Material 8 Depth e <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: --/-- Number of bedroorSts <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK f00"Type/Mfg Capacity IL00® No. Compartments ` <br /> PKG. TREATMENT PLT. Ll # "� ­-"^r'''Method of Disposalof <br /> •{`Ali <br /> Distance to nearest: Well tO Foundations Property,Lined <br /> LEACHING LINE Cl No. & Length.of lines 'Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel{ 0 Foundation _ .____. Property Line <br /> SEEPAGE PITS 11 Depth ;f Size Number <br /> SUMPS LI Distance to nearest: Well Fouh'dation Property Line <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."Contractor's hiring or sub-contracting 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 appMl=` <br /> r all required inspections. Complete'drawlrig on reverse side. ?, q <br /> Signed Title: — Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ ■-- 4a- - ,�,„Ao��,,, �, Date res 0 2- <br /> Pit or Grout Inspection by Date Final Inspection by Dat* <br /> Additional 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 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT RUE AMOUNT REMITTED/ CK RECEIVED BV DATf PERMIT'NO. <br /> ' INFO <br /> . EH13-24tREV.tin51lj / � �� <br /> FH t4-2a �// <br />