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APPLICATION <br /> SIR # S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES — "! <br /> ENVIRONMENTAL HEALTH DIVIS A I D # <br /> 445 N SAN JOAQUIN,PHONE(209)4b - 20- <br /> P O BOX 388,STOCKTON,CA 95201 <br /> PERMIT EXP Y S 1 Y FROM D T -< ID <br /> (Complete in Triplica <br /> Application is hereby Made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County DevelopmentTitleSection 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address loon _ P-0f� 0) _ City LA'f[t/)5 Lot Size/Acrevge <br /> Owner's <br /> Mo. tit C-_4.— Address a f-T//�4 �� � _ Phone?-V --3--z_2I <br /> Contractor _ Address to License No, iS'J `l`/Phone W3 `_77 :3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation �� fa I asing <br /> N Domestic/Private 0 Gravat Pack C1 Tracy Type of Casing_ a <br /> I-I Public 1-1 0.14r . 1­1Delta Depth of Grout Seal n y �t�wi O <br /> I I Irrigalion _Approx, Depth l I Eastern Surface Seal Installed by res 7 2 imt <br /> Repair Work Done U Type of Pump H.P. —_ Stale Wor � <br /> � a1�111t,��i na <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth p1 i€ i I,- <br /> Depth <br /> fGDepth _ Filler Material A Depth ENVfR0N1 F ' ',rl'SION <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONiJ.-r REPAIR/ADDITION I IOESTRU TION I I (No septic system permitted if public sewer is <br /> ..� available within 2{)0 feet-f <br /> Installation will sorra: Residence_ Commercial V-� Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: S'1cei( L bo�n Water table <br /> SEPTIC TANK �T depth <br /> ype/Mfg p�� or��s'r e•�- Capac:y�Z:1 On No, Compartments <br /> PKG. TREATMENT PLT. ❑ hi �� S Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE P�No. b Length of lines ,f�lT - Lam, Total length/size { <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number, <br /> SUMPS LI Distance to nearest; Well Foundation Property Lina <br /> DISPOSAL PONDS p <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 /> Home owner or licensed agent's signeruro certifies the following; "I certify that in the performance of the work for which this permit is issued. I shell not <br /> employ any person in such manner pis to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracling signature <br /> certifies the following: "I Certify that in the performance of the work for which this permit is issued, I shall employ persons aubject to workman's compensa- <br /> tion laws of California." <br /> The sp�icant must call for a►( required inspections. Complete drawing on reverse side, <br /> Signed `'j Title: Data: <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date Areip <br /> ��, <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r, <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.Boa 388,Stockton,CA 95201-0388g60j0�0 <br /> INFO AMOUNT DUE AMOUNT REMITTED CA9H <br /> RECEIVED BY DATE PERMIT'NO. <br /> EN 17-21{i1 1/.i/n SJ�/✓ 1141,�0 14 o x(f <br /> Eli 11-7e �- <br />