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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 C(apy <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 /> Job Address I- oAo0 City_� Lot Size/Acreage <br /> Owner's Name 9'1 y` `jy,'� Address �� t L W��105 �D� u n Phone <br /> Contractor FCL/ E��Q Address _S GCDc!+ICA Dr — License No. N+ Phone _ <br /> TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT Fl DESTRUCTION Ll Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER F]_-� on toring, well5011 <br /> 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 /> Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation 6 Dia. of Well Casing /VA <br /> * Domestic/Private O Gravel Pack O Tracy Type of Casing_.__--/1�'/� Specifications (Q� <br /> I'I Public 1-1 Other I 1 Delta Depth of Grout Seal S _ Type of GroulwA r <br /> 11 Irrigation _._ Approx. Depth I I Eastern Surface Seal Installed by_E621.- <br /> Repair Work Done IJ Type of Pump H.P. _ _ State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms _. <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK O Type/Mfg _-_ _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well . Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth __ Size — Number <br /> SUMPS 1-1 Distance to nearest: Well _ Foundation Property Line <br /> DISPOSAL PONDS U <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 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 /> ceruHes 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 applicant must call for all re ired i tions. Complete <br /> 11 drawing on reverse sidle. <br /> Signed X A-f17 Title: 14 6 CT S' Date: <br /> FOR DEPARTMENT USE ONLY <br /> C <br /> Application Accepted by tom " _ Date A e <br /> Pit or Grout Inspection by ��I Date Final Inspection by Date 1 7 <br /> Additional Comments: <br /> Apt,IIrnnt. - 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH KIf 7 RECEIVED BY DATE PERMIT NO. <br /> • <br /> FH 13 211RfV, rin5r <br /> 14 <br /> EH 1�20 `4 --� �O w I�JSS 6—f 9y•zss� <br /> ,_/ <br />