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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 0 BOX 2009, STOCKTON, CA 95201 <br /> -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appli ton is hereby made,t,4 IJ.Aq.i.—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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> t <br /> Job Address ! City &-t Size/Acreage <br /> Owner's Name Addresses L' Phone <br /> i <br /> jj <br /> Contractor S ,t �` �b Address ►�� {1�l-� License Nov Phone �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well C7 <br /> 1 <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 SPEC IFICATIO IC <br /> n Industrial ❑ Open Bottom ❑ Manteca Die. of Wail Excavation Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I"I Public M Other n Delta Depth of Grout Seal /V Type of Grout N <br /> l I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed try <br /> Repair Work Done 0 �yff�s Pump H.P. State Work Done 477 _ <br /> Well Destruction ❑ 0Diimeter sealing Materiali Depth <br /> Depth Filler Material fs Depth 1MSe! '� <br /> I / G� 1,01a <br /> TYPE OF PTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ]� <br /> available within 200 feet.) [\ - <br /> Installatio will serve: Residence— Commercial — Other �! /�� e X} <br /> Number of live .ts: Number of bedrooms Cs,�J !` ! 0" "� { <br /> Character of soil to a depth o l Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �f <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: ell Foundation rty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line '1 <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 compensa <br /> tion laws of California." <br /> The applict must tail for aired inspections. Complete drawing on reverse 'de. <br /> Signed X_ Title: Date:, ( 3 <br /> FOR rPAPTMENT USE ONLY � <br /> Application Accepted by <br /> Darte � � raa <br /> Pit or Grout Inspection by Date Final Inspeclon y- AS <br /> j i <br /> W,V <br /> Additions! Comments: c Q Was C4 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE P]ERMIT'NO. <br /> . EH,3.2,(REV.i i n 5) <br /> EH 114-26 LL <br />