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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 />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 <br />Hea.1thServices. <br />.JooAddress �� l `�Lilyi4ncr LgYIC :v C � 1 Lot Size/Acreage <br />4 ( J 23ct= # <br />Owners Name 'Elje N t1,1��1 \ A Address �t� L C c� f L 5 Phone <br />Contractor <br />address T,G. B. x Igjq+B(oyit; <br />TYPE OF WELLPUMP NEW WELL <br />PUMP INSTALLATION C <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION <br />IC cense No. <br />YELL REPLACEMENT DESTRUCTION �; Out of Service Well Z. <br />SYSTE"/1 REPAIR OTHER C Monitoring Well <br />SEWER LINES DISPOSAL FLD. PROP _INE <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />NTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS I/, <br />Industrial <br />L7 Open Bottom <br />a Manteca <br />Dia. of Well Excavation �.v" Dia. of Well Casing <br />r <br />Domestic/ Private <br />0 Gravel Pack <br />7 Tracy <br />Type of Casing_ Specifications <br />" Public' <br />1 Other <br />1 Delta <br />Depth of Grout Seal w Type of Grout t C <br />Irrigation — Approx. Depth i Eastern Surface Jeal installed by <br />Repan Work Done Type of Pump - P. State Work Done <br />Weil Destruction 0 Well Diameter rivaling Materia- b Depth <br />Depth Piller Materia': i Depth <br />TYPE OF SEPTIC WORK. NEW INSTALLATION i REPAIR AODIT!nN DESTRUCTION iNo septic system permitted it public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial <br />Number of living units: Number of bedrooms <br />Character of sod to a depth of 3 feet: <br />SEPTIC TANK -:I TVpe/Mfg <br />PKG. TREATMENT PLT. 0 <br />:ther <br />Water table depth _ <br />-aoacity No. Compartments <br />Method of Disposal <br />stance to nearest: Well=oundauon <br />LEACHING LINE =l No. d Length of lines <br />FILTER BED 0 O.stance to nearest: <br />Well Foundation <br />Property Line <br />Total length/size <br />Property Line <br />SEEPAGE PITS I I Depth Size Number i <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS –' <br />I hereov certify that t have prepared this application and that the work wiii be done in accordance with San Joaquin county ordinances, state taws, 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 workmen s compensation laws of California. ' Contractors hiring or supcontractfng 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 applicant must call for all required inspections. Complete drawing on reverse side. <br />Signed X i Title: L�cc'� �'�. iS 7� Date: Z <br />Apv <br />FOR DEPARTMENT USE ONLY <br />/ <br />C t. 3 <br />Application Accepted by Data Area ` 603 <br />Pit or Grout Inspection by rte% Date �� r nal Inspection by/ Data <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 Sox 2009, Stkn, CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTED _`"SH <br />INFO RECEIVED BY j GATE P <br />j (a6.r�A 6a D o 117P k-cS' /� j <br />ge 13.4 <br />