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APPLICATION <br /> " JOAQUIN COUNTY PUBLIC HEAH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 <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 /> qq L TTz-+�-vS <br /> Job Address /C ��MN ./i`CrT �i�• _ City : �� zZ7rd Lot bite/Acreage/i/l 7 i=`ciy <br /> Owner s Name .G,' � ��-/�i(1S _ Address < Phone <br /> 1 <br /> L-�i✓J.77^I/A /�4rIC i AerG i <br /> Contfactov6le21r_c,_ rYrG!'/�7"/CA/Address77'i// -1q-4U License NOA�CZZ7201�'_ _Phone <br /> TYPE OF WELL/PUMP NEW WELL IT WELL REPLACEMENT Fl DESTRUCTION 0 out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 /> laaivatsaal/7cNilD/� ❑ Open Bottom ❑ Manteca Dia of Well Excavation I, 'r Dia of Well Casing <br /> Cl Domestic/Private _Gravel Pack' ❑ Tracy Type of Casing_ 3 Z/L Specdreations <br /> I I Parblic 11 Other Pr-Delta Depth of Grout Seal Z42 -/Z/ Type of Grout r� <br /> I I IrnUataon , O Appro■ Depth f I Eastern Surface Seal Installed by y <br /> Repair Work Done U Type of Pump H P State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> T F SEPTIC WORK NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permuted if public sewer <br /> available within 200 feet I <br /> installation vwll Residence_ Commercial_ Other <br /> Number of living units Number of bedrooms <br /> Character of soil to a depth of 3 feet of table depth <br /> 5EPTIC TANK ❑ Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well own Property Line <br /> LEACHING LINE Cl No A Length of lines engthlaasa <br /> FILTER BED ❑ Distance to st Well Foundation Pro Lrne <br /> SEEPAGE PITSDepth Save Number <br /> :SUMPS LI Distance to nearest Well Foundation Property Line <br /> AL 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 taws and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent a 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 Contractors hiring or sub-contracting signature <br /> certifies the following I comfy that in the performance of the work for which this permit is issued 1 shall employ persons subject to workman a compensa <br /> iron laws of California <br /> The applicant u it for <br /> ail required,inspections Complete <br /> ndrrawwinn on r v se side f ' ( II l <br /> Signed X- �i�r--}�r' ��` `"��f�] 11*'D�.±-. �-SAL Title i AAet."t, date ` [3 + ``1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by 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 CI Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 NO <br /> Eli :3.24 rnEV a r sr <br /> EH a4.2a <br />