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APPLICATION <br /> II <br /> I` 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 /> I I 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. <br /> Job Address City , 'Lot Size/Acreage 1 z y'AR acrig <br /> , � �� _ ` — --- <br /> k Owner's Marne _ Address Phone <br /> ip@' r`�\#dress <br /> License No. �t Phone <br /> Contractor a.� <br /> j TYPE OF WELL/PUMP: NEW WELL ❑ WELL EPLACEMENT n DESTRUCTION .. t of Service Well <br /> PUMP INSTALLATION DSYSTEM�REPAIR,❑ OTHER p Monitoring Well <br /> DISTANCEJO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLFD ""�° PROP. LINE <br /> i; FOUNDATION AGRICULTURE WELL L` -0_T.HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF,WELL PROBLEM AREAL CONSTRUCTION SPECIFICATIONS _ \\ <br /> 11 Industrial ❑ Open Bottom 0 Manteca •'Dia'of Well Excavation F._y .m.--� Dia. of Well Casing <br /> D Domestic/private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il Public 1 CI Other fl Delta Depth of Grout Seal �f Type of Grout <br /> I I IrrigationIs. _ Appro11 x. Depth I I Eastern Surface Sea! Installed by <br /> Repair Work Done 0 Type of Pump H.-P- Stats Work-Done.. -- <br /> Well Destruction Well Diameter Sealing Materiel i Depth + <br /> -Fi11er'Materfal-& Depth <br /> Depth <br /> F TYPE OF SEPTIC WORK: NEW IN$ ALLATION I 1 REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is <br /> J available within 200 teet.l <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms ' t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ,.,; <br /> I t <br /> LEACHING.LINE ❑ No. & Length of lines Total length/size r <br /> FILTER BED C-1Distanceto nearest: Well Foundation Property Line <br /> � fr <br /> SEEPAGE PITS 11 Depth f Size Number T! _ <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 dons 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 candies 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." Contractors hiring or subcontracting 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." i <br /> The app i t u all r aA/rii;6donspe.ctions. Complete drawing on r rse side <br /> f�Signed Title: ���� Date: <br /> li FOR DEPARTMENT USE ONLY <br /> Application,Accepted by _ 1 - Date V- Aram <br /> Pit or Grout Inspection by Date—.Final Inspection b Dat <br /> Additional Comments: 1 <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 /> 5 <br /> FEE AMOUNT DUE AMOUNT REMITTED ECEIVED BY DATE PERMIT'NO. <br /> INFO �r <br /> A . EH 13-24IREV.r/M5) D �Q O <br /> EH 7/.26 Il <br />