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J11APPLICATION 0�.�/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 r <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <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 /> l� � t• <br /> Job Address _� � ` ;t_ �� d i't�� - - City .64Lot Size/Acreage <br /> Owner's Name1Address Phone <br /> Contrac��iar `s y - Address Y �' T License No r u '� Phont'�� <br /> f TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Servide Well ❑ <br /> PUMP INSTALLATION E) SYSTEM REPAIR ❑ OTHER ❑ Monitoring'Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> k <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack f y ❑ Tracy„ Type of Casing_ Specifications <br /> F] Public f-1 Other n Delta Depth of Grout Seal Type of Grout " <br /> I I irrigation Apprgx. Depth I I Eastern '�. 5urfaee Seal Installed by <br /> Repair Work Done ❑'. Type of Pump '--H.P. State Work Done j <br /> x Well Destruction ❑ Well Diameters Sealing Materiald< Depth <br /> Depth.- t . Filler Material & Depth <br /> [ TYPE OF SEPTIC WORK: NEW INSTAL LATION..l-1-•REPAIR!ADDITIO DESTRUCTION l I ;No septic system permitted if public sewer is <br /> available! within 200 feet.) <br /> installation Willi-6 ve Resi­erica-_ Commercial_ Other - ° t- <br /> r j <br /> Number of living'bnits: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth i { <br /> SEPTIC TANK. O Type/Mfg : Capacity - x No. Compartments t E <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest; r Well Foundation Property Line E <br /> LEACHING LINE Cl No. 8 Length of'lines r Total length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundation— - Property Line t <br /> F �d <br /> SEEPAGE PITS i I Depth Size, Number <br /> e <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line a <br /> DISPOSAL PONDS ❑ <br /> t I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> i ruies and regulations of the San Joaquin County <br /> (j 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 applic t must -"�nfo�r aN' egwr specti ns.-Complete drawing on revarse•side: - <br /> Signed X^ U``��� Title: �� t Date: <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by ^r[4w� 141wc \�.4s-A. --__ Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date Z �/ <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, P 0 Sox 2009, Stkn, CA 95201 <br /> EV. INFO FEE AMOUNT DUE AMOU�INT REMITTED CK III <br /> CASH RECEIVED BY DATE PERMIT'N0. <br /> r EN 13'24 IRM �� / r Q G `9 <br /> EH 14-25 17—_1 <br />