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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420PA Y1E - ' <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RJECEI VEL <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE§1_P 0 2 <br /> (Complete in Triplicate) SANJ0A, qr, <br /> PUS 21 1, r,uI qv-r <br /> Application is hereby trade to Ban Joaquin County for a permit to construct and/or i ' �r� gibed. This i <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and d�3s i$Lsy�i ]lettrb`Dns of San <br /> Joaquin CountyPublic Health Services. �lViSfON <br /> Job Address 9`-�a �`'` -Sr City Lot Size/Acreage <br /> Owner's Name �ir%/1V r.� �3 Phone <br /> 37 <br /> Gonttactor`s�Ud I�!`-'-'� �i iltr r�Addressf �lJS� �L�ce se No. X06-3/c Phone �p <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION XOut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ 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 /> n Industrial IDOpen Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing - v <br /> y� <br /> C:1 Domestic/Private ❑ Gravel Pack >3.'q"racy Type of Casing_ � _ ^_ Specifications_X-c-60-1- - <br /> I'1 Public 1-1 Other r Delta Depth of Grout Seal ' Type of G_rf t ' <br /> I i Irrigation w..._Approx. Depth I I Eastern Surface Seal Installed by L�%?��:.f�� <br /> Repair Work Done 0 Type of Pump /J� H,P. Siate Work Done_ -� <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth / <br /> Depth _ / Filler Material ii Depths <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 1 1 REPAIRIADDITION { I DESTRUCTION I I (No septic system pe if public sewer is <br /> available wit feet.) <br /> Inst tion will serve: Residence_ Commercial_ Other <br /> Number of living Number of bedrooms <br /> Character.of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal , <br /> Distance to nearest: ell Foundation rty Line <br /> LEACHING LINE ❑ No. ALL th of lines Total length/size i <br /> FILTER BED ❑ D' tgnce to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number J <br /> SUMPS Ll 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 laws, 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 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." <br /> The applicant must call for all require spections. Com [?to drawing on reverse side. <br /> Signed Title: _ IdPL✓112 /e_- - Date: g ? <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area �-3 <br /> Gj <br /> Pit or Grout Inspection by Date ` Final Inspection by Date <br /> r <br /> Additional Comments: `T <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Rox 2009, Stkn, CA 95201 <br /> FEE <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH". RE/C�EIIV-E--D•BY Q DATE /SPERMIIT'f�NO. <br /> EH 13-241REV.tin Ss <br /> EH 142E <br />