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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONO <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED Alt /// <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 i9 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 /> )(Job Address 2s l T-t t City�-' s_ �y� Lot Size/Acreage <br /> )(Owner's Name Q(,J Os Address 0�+�]-3 t Ute, r � Phone <br /> k X-Conlydclor. 1J� 1 �Y[� Address i'AE,f��C� _ License No. ����� Phone 2c 7 �1-7.3-� -f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll 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 /> 171 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack D Tracy .-Type of Cising_ _ Specifications <br /> Il Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth", 11 Easifern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth f, r <br /> Depth _ Filler Material 6 Depth` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 I- REPAIRIADOITION IJ DESTRUCTION iNo septic system permitted if public sewer is <br /> A f -available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ other + <br /> Number of living units: Number of bedrooms.� <br /> Character of Boil to a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line V <br /> LEACHING LINE ❑ No. & Length of linea r <br /> g Total length/size � <br /> FILTER BED ❑ Distance to nearest: Well "Foundation Property Line'— <br /> SEEPAGE <br /> ine'SEEPAGE PITS 11 Depth Size" — Number {, <br /> E SUMPS Ll Distance to nearest: Well Iodation Pro <br /> party 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 shelf not <br /> employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify 7qi <br /> thZe. <br /> ormance of the work for which this permit is issued, I shall employ p p y persons subject to workman's compensa- <br /> tion laws of Cali ornia." <br /> The applicant c 11 for II r ' tion. Complete drawing on reverse side. c <br /> Signed ��� Titie: Date: _ (c? <br /> 7� <br /> gr�EPAFRITIVIENT USE ONLY <br /> Application Accepted by Date Area' <br /> Pit or Grout Inspection by Date Final Inspection by Date �o <br /> Additional Cammsnts: <br /> 4q-3 <br /> Applicant _ Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO �y CASH �RECEIVED BY / DATE PERMIT'NO, <br /> . EN 19.2 1REV.FixS! 1 r ©O 7�� G� -94f <br /> EH 11.26 - <br />