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APPLICATION OR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />f P 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />,I (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 wade is compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin Count Public Health BeZkkk <br />{�(\�'nyJ� <br />City ASAL Lot Size/Acreage <br />Job Address �i, � f <br />Owner's Name Address Phone <br />A <br />,} t zj K <br />tN A c 2 ease No. i hone <br />TYWELL REPLACEME T Cl DESTRUCTION 11 Out of Service Well D <br />PE OF WELL/PUMP: NEW WELL <br />PUMP INSTALLATION SYSTEM REPAIR ;_1 OTHER >.J tdottitorlrtg Well LT <br />DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. e PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL j PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGIFIC-ATIONS— <br />C1 duc[nel O Open Botiom O Manteca Dia. of Well Excavation Dia. of Well Casing <br />mastic/Private 0 Gravel Pack ❑ Tracy Type of Casing__ ` -� Specifications I — <br />/ ('1 P.blic (-1 Other f (l Delta Depth of Grout Seal Type of Grout <br />A ox.� l astern urface 5eul Installed by <br />I Irrigation pPr I ,�. - <br />Repeir Work Done L� Type of Pum H.P. Stati Work Do - - <br />Well Destruction "C WeII Diameter Sealing Material i Depth <br />Depth Filler Material Z Depth' <br />TYPE OF SEPTIC WORK; NEW INSTALLATION -1 I REPAIR /ADDITION { I DESTRUCTION`1-i -(No septic system permitted of ;Public sewer a <br />available within 2W feet.) <br />Installation will serve: Residence —�-Comrnercial Other <br />N bar of IMn units: � Number of bedrooms <br />V <br />umti` <br />Character of sell to •depth of 3 feet:, <br />AMOUNT REMITTED K , <br />�t <br />CEIVED BY <br />Water table depth <br />SEPTIC TANK O <br />Type/Mfg <br />Capacity <br />No, Compartments <br />PKG. TREATMENT PLT. El <br />Method of Disposal <br />Distance to nearest; <br />Well <br />Foundation <br />Pfopeny Line <br />LEACHING LINE Cl <br />No. b Length of lines <br />Total length/sizo <br />FILTER BED Q <br />Distance to nearest: <br />) <br />Well <br />Foundation <br />Property Line <br />SEEPAGE PITS 1 I <br />Depth f <br />Sire <br />Number <br />SUMPS LI <br />Distance to nearest: <br />Well <br />Foundation .._ <br />Property Line j <br />rIICPC1gAk Pr1Nr1Ft F1I- <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, end <br />rules and regulations of the Sen Joaquin County ((( <br />Home owner or licensed agent's signature cartiflet the following: "I certify that in the performance of the work for which this permicis issued, I shall not <br />employ any person in such manner as to become sub}eci to workmen'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 i3 issued, I shall employ persons subject to workman's compenw- <br />tion laws of California C <br />The apptie Du <br />st call ford ired I spections. Complete drawing on ra er side. ` <br />Title: }. Dme: ' <br />Signed � -f " <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by _ G_=�, —.Date :77-� Q Area <br />Pit or Grout Inspection by Y' T LData Tm- final lnapeotian by Dat. <br />Additional Cornmants: <br />Applicant - Return all copies to; San Joaquin County public Health Services n <br />Environmental Health Permit/Services le `� <br />` 445 N San Joaquin, P 0 Bot 2009, Stkn, GA 95201 <br />. EH 13-2411•EV. <br />rir.s <br />EH 14 24 <br />FEE AMOUNT DUE: <br />AMOUNT REMITTED K , <br />�t <br />CEIVED BY <br />DATE PERMIT' NO. <br />INFD <br />7/% <br />I <br />