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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> JAN 2 Q 193 <br />'i P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 coiapliance .with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job AddressCity _ Lot Size/Acreage <br /> Ar� - <br /> Owner's Nam e_a lrJ� AdkssLA__^- � Phone <br /> Contract AddreL J "&� --J&jOV License <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ` STRUCTION ❑ Out of Service Well ❑ , <br /> PUMP INSTALLATION i—` SYSTEM REPAIR OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> -« FOUNDATION AGRICULTURE WELL_ OTHER WELL--PITS/-SUMPS, <br /> -PITS/SUMPS: _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } <br /> C7 Industr Cl.❑ Open Bottom Manteca Dia. of Well Excavation pia. of Well Casing <br /> " <br /> Private :❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public Cl Other fl Delta. Depth of Grout Seat Type of Grout <br /> I I Irrigation Approx. Depth I I'Eastern { «Surface Seat Installed by' , <br /> Repair Work Done Type of Pump H:P, _ State Work Done i <br /> Well Destruction O Well Diameter Se—oXV4-Material-w3-Depth . <br /> Depth ­-Filler.:Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is II <br /> available within 200 feet.). <br /> Installation will serve: Residence_ Commercial_ Other J, ""; <br /> Number of living units: Number of bedrooms r <br /> Character of soil in a depth of 3 feet: <br /> Water table depth <br /> 9 Capacity No. Compartments <br /> SEPTIC TANK 0 Type/Mi " f <br /> PKG. TREATMENT PLT. ❑ :; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well foundation Properly Line <br /> SEEPAGE PITS I'I Depth Size Number <br /> SUMPS Cl 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 Jbaquin 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 to become subject to workman's compensation laws of California." Contractor's hiring otsub-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 .all reu�- �tms:Complete drawing on a arse side. <br /> Signed X <br /> Title: Date: _ 4 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by M , - qj <br /> Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date r7A3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San. Joaquin County Public Health Services <br /> Environmental Health Permit/Services i <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED _ CK RECEIVED 6Y DATE PERMI7'ND. <br /> 40, <br /> INFO CASH <br /> } (REV.t/is 51 <br /> EH 14.28 r0 ��� 33b ✓ . <br />