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APPLICATION. <br /> SAX JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN; PHONE (209)468-3420 <br /> P O 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 complianceivith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services., e <br /> �� �, � `4(/` City�c1 C ` Lot Size/Acreage <br /> Job Address k <br /> f 1 ✓ <br /> Owner's Name Address <br /> r' <br /> Contractor r] Address License N Phone <br /> service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT [__1 DESTRUCTION LI Dut of <br /> Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR,;?.Ie OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL. ""OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Tracy <br /> n Industrial Open Bottom"" 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r T r Specifications n <br /> =t 1 Domestic/-Private 'El GravehPack CS Type of Casing_ <br /> Type of Grout <br /> I'] Public <br /> I-1 Other 1-1 Delta Depth of Grout Seal <br /> /PNprIrrigation Approx.{Depth I Eastern <br /> , <br /> Surface 5ea1 InsCalled.by <br /> , p H,P. State Work•Done <br /> Repair Work Done .t� ry�Type of Pum dr Depth <br /> Well Destruction ❑ Well.Diameter Sealing material <br /> Depth Filler Material rE Depth <br /> �1 <br /> TYPE OF SEPTIC WORK;—NEW-INSTALLATION t I REPAIRlADDITION 1 1 DESTRUCTION available <br /> l 1 septic system permitted if public sewer is I <br /> available within 200 IseLI <br /> Installation will serve: „Rssidence,.J1 Commercial^ Other F <br /> s i <br /> Number of living units: �. Number of bedrooms <br /> Water table depth <br /> Character of'soil to,a_depth.af.3 feet; - <br /> - <br /> SEPTIC TANK± 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � <br /> " Method of Disposal ` I <br /> Distance�t'o nearest: " Well ` foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance)to nearest: Well Foundation Property Lias <br /> i <br /> SEEPAGE PITS 11 Depth Size" Number <br />` SUMPS 0 Distance to nearest: Well Foundation Property Line ` <br /> I DISPOSAL PONDS ❑ <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, and <br /> rules and regulations of the San Joaquin County <br /> that in the performance of the work for which this permit is'issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify <br /> employ any person in such manner as t!d 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." f <br /> Theapplica 7uff'xall for all required inspee ions. Complete drawing on rev a side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ "= Date Arse <br /> Pit or Grout inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> l <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> ka1AEl! AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13-EH 241REV.rixs�6 L? <br /> r <br />