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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> 45 N SAN JOAQUIN, HONE (209)46$-3420 f <br /> e 4 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> IPERMIT F�PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby <br /> made to San}Joaquin dounty for a permit to construct and/or install the work here <br /> Application <br /> This <br /> application is wade in compllaSanSxlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. q 1' <br /> City <br /> Lot Size/Acreage <br /> Job Address <br /> / � � Phone <br /> Address4�� _ r <br /> Owner's Name C, Phone 3& 31 <br /> -' <br /> ddress -Y License No. <br /> Contractor DESTRUCTION ❑ Out of Service well ❑ <br /> NEW WELL ❑ - WELL REPLACEMENT C7 OTHER ❑ Monitoring Well �� <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION DISPOSAL FLO. PROP. LINE <br /> SEWER LINES. ;. — <br /> Dk5TANCE TO NEAREST: SEPTIC TANK �---- PITS/SUMPS ��- <br /> �..FOUNDA710N_ _y—AGRICULT,_URE W.ELC� _ ,- BOTHER WELL- - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CAT10NS pia. of W611 Casing. <br /> i Dia. of Well.Excavation <br /> n <br /> Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Gravel Pack 0 Tracy Type of Casing- <br /> fl Domestic/Private `+,Type o1 Grout <br /> 1-1 Other Cl Delta Depth of Grout Seal <br /> I'] Public k _ Surface Seal Installed by <br /> lrri{}ation Approx. Depth I 1 Eastern State Wor�Don6 <br /> of Pump H.P. <br /> Repair Work Done U Type Sealing Material i Depth <br /> Well Destruction E] Well Diameter --- Filler Material 6 Depth <br /> Depth i rmitted,if public sewer is <br /> S-� ; available within 200 feet.1 <br /> `. r <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION I 1 REPAlfllADDtTION l I DE57RUCTION I,l INo septic system <br /> Installation will serve-, Residence Commercial— Other <br /> Number of living units: Number of bedrooms PAYME Tater table depth <br /> Character of sail to a depth of 3 feet: Capacity o. Compartments <br /> SEPTIC TANK 0 Type/Mf9AY 1 1 '�ethod of Disposal <br /> PKG.jREATMENT PI.T. ❑ �+ nearest: Well FoundatiI 0 Property Line <br /> Distance to on <br /> SA J AQUIN CQI_i�TY <br /> LEACHING LINE ❑ No. &�Gength of lines Property <br /> Line <br /> t - <br /> FILTER BED r] Distance to nearest: Well <br /> Foundation Property <br /> 11 <br /> —Size Number <br /> SEEPAGE PITS it Depth Property Line - - <br /> Ll Distance to nearest. Well Foundation <br /> SUMPS _ <br /> �-DESPOSAl'PQNDS''�❑ <br /> }µ <br /> ith San Joaquin county ordinances, state laws, and <br /> I hareby certify that I have prepared this application and that the work will be done in accordance w <br /> i rules and regulations of the San Joaquin County g -„ work for which this permit is issued, I shall not <br /> Ik Home owner or licensed agent's sigr.aiurs certifies the followri I certify that in the performance of the signature <br /> f employ any person l in such ma that n the performance i to become cof the wok fot to rwh chethis permiation t is issued, I shall s of lemp employ persons lsubject to workmanlsgcompensa- <br /> certifies the following,.g <br /> Non laws of California." <br /> The applicant ust ca11 r all required inspections. Complete drawing an reverse side. <br /> Date: <br /> Title:. <br /> Signed X <br /> FOR DEPARTMENT USIE O LY <br /> Date 1 �� Area <br /> Application Accepted by 1 11411 <br /> k t E Date �—�- Final inspection by = --- <br /> tl Pit or Grout Inspection by <br /> t Additional Comments: alth <br /> He <br /> Applicant - Return all ,- to: Environmentalan Joaquinounty HealthuPermit/services <br /> vices <br /> ] 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED RY DATE PERMIT'NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 111-24(REV, <br /> EH 14-25 <br />