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APPLICATION <br /> -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION &WA^ <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ^fo �� ,, <br /> P 0 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 i <br /> application is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 5 City S 7,t.J Lot Size/Acreage <br /> Job Address <br /> Owner's Name Ua,t�NA A 2A16�. Address Phone <br /> S/!�� <br /> FG p �-o'D Address, Z AA -"4- 7- AJe License No. !Y xgL Phone s-3�7 <br /> Contractor _ �D <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER ❑ Monitoring Well � <br /> DISTANCE TO NEAREST: SEPTIC TANK F <br /> r SEWER--LINES--p• --DISPOSAL FL-D PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS__ Dia. of Well Casing <br /> n Industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications- — <br /> f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> I'I Public <br /> i..1 Other Cl Delta Depth of Grout Seat Type of Grout <br /> ( I Irrigation .Approx. Depth it Eastern Surface Seal installed.by <br /> Repair Work Done CJ Type of Pump H.P. State Work Done <br /> Sealing Material Depth <br /> Well Destruction ❑ Well Diameter <br /> 6 <br /> Depth Filler nri �'�TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AD RUCTION iNo septi ystem permitted if public sewer is <br /> available ithin 200 feet.) <br /> Installation will serve: Residence TCommercial Other; <br /> �F <br /> Number of living units: Number of bedrooms <br /> Character•of-soil ao a-depth of 3.feet: :' <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ` Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE ElNo. & Length of lines Total length/sire <br />{ FILTER BED C7 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size ' Number <br /> SUMPS LI Distance to nearest: Well ' Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> at the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and th <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 sanity 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 required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: _6111z: Date: G 2,a:--9 3 <br /> F R DEPARTMENT�brtY <br /> Application Accepted by DateArea a <br /> Pit or Grout Inspection by Date Final Inspection by ata <br /> / 7 <br /> Additional Comments <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ro r <br /> Environmental Health Permit/Services l! <br /> 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERM17'N0. <br /> INFO <br /> . <br /> EN I7•24 IHEV.t I's sl <br /> EH 14.90 <br />