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APPLICATION <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 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 <br /> Health Be cea. <br /> j Job Address ��? '�'" —'c City Lot Size/Acreage <br /> Owner's Name — 3 Address Phone <br /> Contrac' ~ dre Cicerise Nt t Phon <br /> * TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT D DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER 1:1Monitoring Well ❑ <br /> �_""`—DISTANCE TO-NEAREST:-SEPTIC TANK- -- SEWER LINES DISPOSAL FLD.. ;R9OP._.LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> r (-1 Iu rial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'l Public Cl Other n Delta Depth of Grout Seal Type dl Grout q _ <br /> t I IrriUation Approx. Depth t 1 Eastern ( Surface Seal Installed by 1 <br /> Repair Work DoneType of Pump -- H.P. �` _ State Work pone <br /> ITS <br /> Sealing Material 6 Depth W. <br /> Well Destruction E? Well Diameter <br /> Depth Filler Material b Depth tPa <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION i I tNo septic system permitted if public sewer is <br /> 4 , available within 200 feet.) <br /> 1 Installation will serve:_ResidenceT-Commercial--„.,,�� -others - <br /> Number of living units:'`t Number of bedrooms <br /> Character of soil to a depth of 3 feet: b th <br /> �+ <br /> SEPTIC TANK ❑ Type/Mfg -Capacity �.� 2: to <br /> - <br /> c-,�PK&TREATMENT PLT. ❑ t �”„`"i � d <br /> 'r a Distance'to nearest: Well Foundation <br /> SAN SRVIC S10M <br /> .Y �py�T;RntyMENIAL TILA— - -- <br /> I LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 <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 /> 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 compen'sa-r <br /> tion laws of California." <br /> The applicant m r all required insions. Complete drawing on reverse side. <br /> Signed X Title: U"&a�L� _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2t� Area �� <br /> Pit or Grout Inspection by.. Date Final Inspection by Date <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;, O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C1C RECEIVED BY DATE PERMIT'N0, <br /> 4 INFO <br /> L 334 <br /> . EH 13-24IREV.��M51 - vi) <br /> 3- f 2 4Z <br /> EH 14.26 '- <br />