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} APPLICATION �D ' <br /> J SAN JOAQUIN COUNTY PUBLIC HEALTH SE ICE y� <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> r" 445 N SAN JOAQUIN,PHONE(209)469-34 0 <br /> P O BOX 388, STOCKTON,CA 95201-0388 1 ` !!,"!! I <br /> PERMIT IRES 1 YEAR F DATE ISSW <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 application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address ,�/ (/!' City Lot Size/Acreage <br /> Owner's Name Y��W� `-"+^W Address 16Z2Phone <br /> Contract Ir f 1ti Address 1 ! License No. Phon <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT P DESTRUCTION ❑ Out of service Well 0 <br /> PUMP INSTALLATION GSYSTEM REPAI,%. ❑ OTHER C1Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,Z= ee SEWER LINES AaW DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL aLQ�THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WON Casing <br /> t fL Domestic/Private C L Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public I-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation .54arApprox. Depth I l Eastern Surface Seal Instilled by L <br /> Repair Work Done U Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Wall Diameter Sealing Material i Depth <br /> Depth biller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION i I DESTRUCTION I l INo septic system permitted if public "war is <br /> available within 200 faat.t <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 ❑ Type/Mfg Capacity Nc <br /> PKG. TREATMENT PLT. O <br /> Distance to nearest: Well Foundation PropertygI�' <br /> A�3�a 59� �► <br /> LEACHING LINE C] No. 6 Length of lines Total (!,)LjNTY <br /> FILTER BED ❑ Distance to nearest: Well Founciation Pl WK1(jAjF LTH SER`JICLS <br /> ENV1R01NMENt_ATTEZTFDM510th <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to neerest: Well Foundation Property Linn <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 10 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 t call for oil required in tions. Complete drawingULI(Rt4 <br /> erse side. <br /> Signed X �l_ L Ci ( �I �, tg _ Title: _ Dole: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �4 �i <br /> T Area p <br /> Pit or rout i apaction by Final Inrt <br /> spection by Data 2 a' ! <br /> Additional Comments: :Z Z, <br /> Applicant - Return all c pies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services {� <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED xt7t H RECEIYEO 8Y DATE <br /> EH ti trtEv.r.�ar ?( p r DtJ �V� l,v� / t/r �y ��g a <br />