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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and tate Rules and Regulations of San <br /> Joaquin County Public Health Services. �1 <br /> ,♦ Job Address `�`0 r '✓ rT - City L � Lot Size/Acreage <br /> •Y/ <br /> ' >� Lar "' • U/r <br /> Owner's Name tLL L � Phonr� <br /> �! !/ Phone j� <br /> t7 <br /> ContraUor , AddressPp License No. f � <br /> (/ TYPE OF WELLJPUMP. NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -❑ Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f] Domestic/Private" ❑-Gravel Pack 61 Tr'aey' Type of Casing_ - Specifications. <br /> I'1 Public I-1 Other 171 Delta Depth of Grout Seal Type of Grout ' <br /> I I irrigation Approx. Depth II Eastern Surface Seal Installed by *Ilk <br /> Repair Work Done 0 Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material 3 Depth <br /> Depth Filler Materi{il 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCT N septic system permitted if c sewer is <br /> a liable within 200 feet. <br /> Instal a I serve: Residence_ Commercial Cather <br /> T i <br /> Number of living units: Number of bedrooms <br /> Character of soil to ayp1h <br /> f 3 feet: L Water table depthSEPTIC TANK. yp'a g apactNo. CompartmentsPKG. TREATMENT PL s , Method of Disposal <br /> Distance to nearest: j Well s oundslion Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size l <br /> FILTER BED n Distance to St., Well Foundation Property Line I <br /> r <br /> SEEPAGE PITS r Depth Size Number <br /> I' SUMPS Ll Distance to nearest: Well Foundation Property line <br /> DISPD ONDS ❑ <br /> 1 areby certify that h have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The appal t mu t call for ( required inspections. Complete drawing on reverse side. <br /> iDuvt�.ey ~! 1� <br /> Signed I Title: -- Date:. <br /> FOR DEPARTMENT USE ONLY y <br /> Application Accepted by M\% Data `� YC�3 Area <br /> Pit or Grout Inspection by Date .Final Inspection b Date <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 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH 53441REV.I/H5) <br /> EH I{•2a <br />