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t 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 /> Appllca:loo is hereby meds 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.Ordinanee No. 549 and 1862 and the Rules and Regulations o: San <br /> Joaquin County Public health Services. a� 5 <br /> ` City rj Lot Size/Acreage a <br /> Job Address d701 6CNAi Part 81 VG JTc• 210 ) �y <br /> Addres <br /> Owner's Name <br /> w I/�r,�1 ,��,J11 �� Phon t <br /> ess .'" "� y iCense NL - <br /> Contractor }. _ s-- <br /> NEW WELL ❑ WELL REPLACEMENT �.1 ' n DESTRUCTION a Out at Service Well yrs i <br /> TYPE OF WELLIPl1MP: - n 4. OTHER Monitoring /`^ <br /> PUMP INSTALLATION Ci SYSTEM.REPAIR � / <br /> ' DISPOSAL FLO. PROP. LINE �3� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> �r Dia. of Well Casing <br /> } Industrial G Open Bottom i ❑ Manteca Dia. of Well Excavation �Lr, <br /> Type of Casing- y -- Specifications ' a <br /> VQI <br /> Cl Domestic/Private Gravel Pack h❑ Tracy �S <br /> �l Delta Depth of Grout Sea! .— Type of Grout <br /> I'1 Public . (-�tOther :� <br /> 1 1 Irrigation 16 Approxi Depth . I I Eastern Surface Seal Installed by �( <br /> of Pump H.P. State Work Done ^ ! <br /> Repair Work Done C7 Type See.l.ing jyaterial i Depth <br /> f <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> j % Depth 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo available eplic system <br /> rented if public sewer s <br /> Installation will serve: Residence — Commercial— Other <br /> Number of living units: Number of bedrooms C <br /> Character of soil to a depth of 3 feet: - <br /> Water table depth <br /> 7FUr6trfts' <br /> SEPTIC TANK 0Type/Mfg :A Capacity <br /> PKG. TREATMENT PLT. ❑ <br /> l <br /> Distance to nearest: Well Foundation Prope�ildne� <br /> 10U <br /> LEACHING <br /> i ice }1 <br /> LEACHING LINE 0 No. & Length of lines <br /> Total lert� i �i <br /> r k � ti hVSL. ,... <br /> FILTER BED 0 Distance to nearest: Well Foundation � P0@40 <br /> I <br /> SEEPAGE PITS I I Depth "F Size Number <br /> r <br /> SUMPS L! Distance to nearest: Well Foundation Property Line <br /> 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 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 permits issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature <br /> cenifies 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." 11 <br /> F The applicant must call tar all required inspections. Complete drawing on reverse sided <br /> 4� <br /> �4 <br /> Title: <br /> D <br /> / � � ate: �. <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> ti Date � Area <br /> Application Accepted by a q r <br /> Pit or Grout Inspection by Date J r 7� Final Inspection by Yet a Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services t � � <br /> Environmental Health Permit/Services <br /> ' ST <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> r <br /> FEE AMOUNT DUE 4 AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> INFO <br /> . EN 13-24[REV.Ir*71 <br /> Ek 14.3 <br />