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APPLICATION OR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 FROld 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 Coun y Public Health Service . <br /> Job Address d CCity Lot Size/Acreage <br /> r­h,'s Name 0111 Phone Z <br /> 1 <br /> onl t > u 10&a � ' ense No. Phone + `� <br /> TYPE OF WELL/PUMP: NEW WE L WELL REPLACEME T ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIO T SYSTEM REPAIR 0 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 /> DC] I dustrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastie/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> /1'l Public 1.1 Other fl Delta --Gepth-of-Grout-Seal. - Type of Grout <br /> I I Irrigation —Approx. De 1 1 Eastern 1 Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. ^I _ _T State Work Don wy— r <br /> Well Destruction ❑ Well Dia , Sealing Material i Depth i <br /> Depth Filler Material i Depth E <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I.I DESTRUCTION I I INo septic system permitted if public sewer is 011 <br /> _47available within 200 feet) <br /> Installation will some: Residence.-.� Commercial Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth o1`3 fe*t. - "` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines--' Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation 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 t <br /> employ any person in such manner as to bacon*subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature V <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 is liforn <br /> The appl" nt at cs req u'ed inspections. Complete drawing on rev side. <br /> Sig Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C _ � au,My_� Date — "' Area d <br /> Pit or Grout Inspection by Date Final Inspection by Date 1 �� <br /> Additional Comments: 4 d = 4,I g 7i Y <br /> -Applicant,-- Return all copies to: Ban Joaquin County Public 'HealthSServices - tT <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Bax 2009, Stkn, CA 95201 <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERMIT'NO. <br /> }l , <br /> . <br /> EK 13-24 IREV.11441 -r 'r (.32- AB er ?2 2 13 7 <br /> EH 148 r <br />