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APPLICATION <br /> SAN tirOAQUIN COUNTY PUBLIC HEALTH SRV I CES <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 San <br /> Joaquin County Public Health Services. f I ''r � <br /> Job Address of tti fl4 4�.'� 4t4 City y4_c �''-- Lot Size/Acreage <br /> Owner's Name ' &LV 150 �I Il��/I Address 3A Phone <br /> Contractor W Oftl�(K Address eral d- License No. �hone-?/6 4364 <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service well O <br /> PUMP INSTALLATION 0 SYSTEM REPAIR O OTHER O Monitoring well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS <br /> /,SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial O Open Bottom a Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private O Gravel Pack 0 Tracy Type of Casing Specifications <br /> Il Public (Other$oil gu .Aj r i Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth ' I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Wgqrk D no_ <br /> Well Destruction O Well Diameter Sealing Material i Depth iC pA. tv1 <br /> OepthSiL AIA- Plln Filler Material i Depth 1 `/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION' I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer 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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest_ Well Foundation Property Line <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 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'ssignature certifies dw following: "I certify that in the performance of the work for which this permit is issued, 1 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 applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: P LJ 0�►1 '1 Date: a <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date ` ` Area <br /> Pit or Grout Inspection byDate __ILL Final Inspection by Date <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE <br /> INFO CASH PERMIT'NO. <br /> . EM $17.24 IREV.i i R sr - Page I3A <br /> EH 11.2a <br /> a— <br />