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4- <br /> APPLICATION <br /> �. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 11 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)408-3420 <br /> }x P 0 BOX 2009, STOCKTON, CA 95201 <br /> IP ERMIT .E%PIRES- I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> e with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application in made in cemlplianc <br /> Joaquin county Public Health Services. <br /> �f IJ ' d City ei4� Lot Size/Acreage <br /> Job Addresses I Y 9 �W t S_A <br /> P A <br /> t 1,LAddrass- 3 d a N Lots Phan <br /> Owner's Name / �/ <br /> Contractor <br /> el. P� Address b �� 'S License Nd. �--Phone? <br /> TYPE OF WELL/PUMP•. � ,NEW WELL ❑, �. � WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well <br /> OTHER C1 Monitoring Well C3PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL f OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom Cl Manteca Dia. of Well-Excavation <br /> Type of Casing_ Specifications <br /> P,Domestic!Private 0 Gravel Pack 0 Tracy Type of Grout <br /> — <br /> (1 Public CI Other Cl Delta Depth of Grout Seal <br /> I I Irrigation APprox. DepTI I Eastern ace Seal Installed by <br /> H.P. I State Work Done <br /> Repair Work Done (►� Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth = /. <br /> -,TYPE OF SEPTIC WORK: NEW INSTAi CATION I I REPAIR/ADDITION I I DESTRUCTION 11 available�w thine200 Ieettted it public sewer is <br /> Installation will serve: Residence_ ._ Commercial— Other <br /> - <br /> Number of living units: Nuxmber of bedrooms ! <br /> r Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. I Capacity F No. Compartments <br /> ❑ Type/Mfg <br /> y " <br /> t ,,�Method.of Disposal <br /> PKG. TREATMENT PLT__❑ _ .r: F .. -',�^ <br /> Distance-to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No.`& Length of lines Total length/size <br /> FILTER BED F} Distance nearest: Well Foundation Property Line <br /> It <br /> SEEPAGE PITS 11 Depth k4. Sire Number <br /> SUMPS 0 Distance to-nearest: <br /> Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done'iri accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall no <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur <br /> certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicPZZR;;� <br /> id iectionsComplete drawing on reverse side. r <br /> Signed X <br /> Title: . Date. <br /> OREPARTMENT USE ONLY <br /> Date A a <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection b ; - Dat <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 O Box 2009, Stkn, CA 95201 <br /> tpfa <br /> CK R CEIVED BY D E PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH =� <br /> . EH 13.24(REV.1/x Sl r ' if+ <br /> EH 14-26 <br />