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• +- - F> Yea. <br /> ADPL I CA7L'I ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> X445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> N PERMIT ExRES 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. 5b9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address — SCCity ^ _ Lot Size/Acreage <br /> Owner's Name rv�= , �qj 7 �¢ Address <br /> Phone <br /> Contractor 0.Ci [. Address License No,�27Phone6 ` a <br /> TYPE OF WELL/PUMP; NEW WELL. ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <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 /> ❑ Industrial 0 Open Bottom C1 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type'of Casing_ Specifications <br /> Cl Public 1-1 Other n Delta Depth of Grout Seal 'Type of Grout <br /> I i Irrigation Approx..Depth L I Eastern Surface Sedi Installed by <br /> Repair Work Done T t <br /> ype ot'Pump. H.P. State 1'/Vark Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth " t <br /> Depth Piller Material & Depth I <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRlADDITION t I DESTRUCTION I I (No septic system permitted it public sewer is <br /> ' <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) <br /> Number of living unite: Number of bedrooms <br /> i <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. ❑ Method of Disposals <br /> Distance to nearest: Well Foundation Propeny,Lins <br /> LEACHING LINE ''` ^' �f \ <br /> CI fVti: & Length o!'lines �. �• f Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Founiiation 'Property Lihd• <br /> SEEPAGE PITS 11 Depth Size Number ` <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <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 F <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 /> ceitifies 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 com r <br /> tion laws of ia." pensa- <br /> The ap ant mu calf for all required spections. Cc eta drawing-onrrever ide. ' <br /> Signed Title; Data: <br /> 9 <br /> F <br /> RTMfN7 U5E ONLY p <br /> Application.Accepted by .� Date <br /> Area C� <br /> Pit or Grout Inspection by Date Final Inspection by ` j <br /> Data� <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, Box 2009, Stkn, CA 95201 <br /> FF AMOUNT DUE AM UNT REMITTED CIC R (EIVED'BY <br /> INFO D TE PEAMIT'NO. <br /> r �[j <br /> . EH 13-2t tREV.iinsii� 6,J 0� - .. • 1 j . <br /> fH 146 / <br />