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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 /> ' PERMIT R IRE <br /> S 3 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 vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 a.nd the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 5915 Sh-c epj city Lot Size/Acre <br /> h Ue.✓ / sae l ae-72 ,. <br />[ Owner's Name _ ��,,, �a � L�1 U Address ams Phone 931-0669 <br /> Contractor C-2alzk Veii, Inc Address 2024 6. ChaA.&az <br /> License No. 3.715 6 0 phone 4627676 <br /> � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Glx DESTRUCTION Out of Service Nell [] <br /> PUMP INSTALLATIONk�L SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK t�)f7 ,` SEWER LINES DISPOSAL FLD. PROP. L1NEI5 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n n ustrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation n Dia. of Well Casing <br /> xGa�� estic/Private XA�] Gravel Pack L Tracy Type of Casing_ n <br /> Specifications <br /> ublic 1-1 Other F1 Delta Depth of Grout Seal _ <br /> I i IrrigationC1�)' Type of Grout- <br /> —.Approx.fDepth I I Eastern Surface Seal Installed b r <br /> Y—Cp <br /> Repair Work Done U Type of Pump a H,P. I State Work Done_ <br /> 42 <br /> Well Destruction Welt Diameter Sealing Material & Depth <br /> 7 9 �cLck <br /> Depth �:� ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION 11 REPAIR/ADDITION 1. 1 DESTRUCTION 1 i (No septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve: Residence ' Commercial_ Other r <br /> Number of living units: Number of bedrooms - f <br /> r <br /> Character of soil to a depth of 3 feet: f <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg� "Capacity No. Compartments r J <br /> PKG. TREATMENT PLT. C7 <br /> Method of Disposal __ f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl — <br /> Na. & Length of lines _ Total length/sire <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> 1 �'G <br /> V # <br /> SEEPAGE PITS 11 Depth Sire Number f <br /> SUMPS Ll Distance to{nearest: Well Foundation <br /> DISPOSAL PONDS p Property Line <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 aignaturelcertifies the following: "I certify that in the <br /> employ any person in such manner as to become subject to workman's compensation lawsoof Californiarmance of ,"Contractowork for r'sch or sub cont acs permit is unglsignaf tune <br /> certifies the following: "I eerfi at in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compansa- <br /> tion laws of Californ! <br /> The applica t all or al it III s. mp to drawing on reverse side. <br /> Signed - Title: VP <br /> r 1a-C— Date: _ 6 0 r J <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by III Date ��a+o Z 4 <br /> i Area <br /> Pit orr u nepection by Data `� Final Inspection by <br /> `'� Date .2 <br /> Additional Comments: o� fZ r7K �r /r 2 1_ = <br /> re <br /> A/pplicant/ - Retur all cop es to: San Joaquin County Public Health Services dCSeT'�L . .r <br /> A. � 3Q�r� Y <br /> i C� Environmental Heal-th permit/Services pU �,�'� `P <br /> t�IZq � 41 N San Joaquin, P 0 Bax 2009, Stkn, CA 95201 J / �q <br /> f IIII` ii INFO CK RECEIVED BYEDEATEPERMIT'NO.FEE ANfOUNT DUE i AMOUNT REMITTED CASHHi13.28IREV.rills!EH i4-Ia ` U� � J ��� �� <br />