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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, STOCKTON, CA 95201 <br /> i. <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 irork herein described. This <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 /> 1.J� <br /> Job Address �; <br /> City Lot Size'/Acreage <br /> Owner's Name l l Address ��l�Gyd-a / Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <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 Q Manteca Dia. of Well Excavation_ pia. of Well Casing <br /> [a <br /> Domestic/Private 0 Gravel POW- a 0 Tracy Type of Casing_ Specifications <br /> Y <br /> Cl Public FI Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 T r <br /> P Type of Pump H.P. State Work Done.— <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I I iNo septic system permitted if,public sewer is Q <br /> available within 200 feet.) <br /> Installation will serve: Residence J Commercial <br /> Number of living units: Number of bedrooms' _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. Type/Mi r ¢� <br /> g Capacity No. Compartments <br /> PKG. TREATMENT PLT.9 y "Il Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance io nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> r <br /> SUMPS Ll Distance to nearest: Well Foundation- Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thit!application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I <br /> rules and regulations of the San Joaquin County - I <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 applican must call for all required inspections. Complete drawing on reverse side. f <br /> Signed " 0LLA <br /> 9 Title: Date: <br /> FEPARTMENT USE ONLY <br /> Application Accepted by- Date —1 <br /> res <br /> Pit or Grout inspection by Date Final Inspection by; Date <br /> Additional Comments: 11 <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 INFO. AMOUNT DUE ;i AMOUNT REMITTED C RECEIVED BY DATE PERMIT'ND. <br /> • EHi3-74 IFIEV.i/h 5! `1l � <br /> EH 114--2114 f / �✓ �✓��O / <br />