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APPLICATION M <br /> l Iu <br /> SAN 'vAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION -_', <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, .CA 95201 <br />€ PERMIT E%PIRES 1 YEAR FROM DATE IQUED <br /> F <br /> (Complete in Triplicate) <br /> Application is hereby made to Ssn 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 <br /> Joaquin county Public Health Services. of San <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address ! ! Phone 6,6 Z, + <br /> Contractor &dill j Address License lvo.J� Phone <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLAG MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER p Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> I] Domestic/Private Gravel Pack' Tracy Type of Casing— Specifications <br /> I'i Public fa Other I ❑ Delta Depth of Grout Seal _f1Ta <br /> Type of GT ut <br /> XIrrigation Approx)Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.H.P. State Work Done <br /> Well Destruction fl Well Diamet ! t Sealing Material & Depth <br /> Depth 3 0 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I f DESTRUCTION I I (No sepllc system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> s <br /> Character of soil to a depth of 3 feet: :i <br /> SEPTIC TANK ❑ Type/Mfg <br /> if Water table depth <br /> Capacity No. Compartments I <br /> PKG. TREATMENT PLT. ❑ 11nearest: <br /> Method of Disposal <br /> Distance Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to 3nearest: Well Foundation_ Property Line <br /> f <br /> SEEPAGE PITS 11 Depth f: Size Number <br /> DISPOSAL PONDS <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> ❑ �`� <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 l]l <br /> aws, and <br /> rules and regulations of the San Joaquin.County e <br /> Home owner or licensed agent's signature! nifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not f <br /> employ any person in such manner as to fiecome 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 <br /> tion laws of Cali rnla." p y persons subject to workman's compensa- <br /> The appil antovst call for all.require I peclions. Complete drawing n revers <br /> Signed X f- Title: <br /> Data: <br /> FOR DEPA ENT NLY <br /> Application Accepted byra r/ <br /> - Date 2'3 Area ! +� <br /> Pit or Grout Inspection by Date Final Inspection by <br /> 1 Data <br /> Additional Comments: <br /> A .' 85'- / cJ <br /> Applicant - Return all. copies; to; San Joaquin Count public Health Services ' <br /> { Environmental Health Permit/Services i <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i <br /> IEEEO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY <br /> ! ` DATE PERMIT'NO. <br /> . EH 13-21(REV. 51 }[ <br /> EH 14.20 <br />