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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 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`vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ' f City f' :;:Lot Size/Acreage I G-��� <br /> XOwner's Name Address �� � l>~ w" �'`Qhone <br /> Contractor 06CmEW Address JV License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ -/ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> C `°PUMP INSTALLATION"❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� <br /> """` ^r'^��"SEI+IiER LIIV.ES L —'�"� QISPQSAL F b?!:`•�� PROP: LINE <br /> DISTANCE TO NEAREST: SEPTIC-TANK <br /> 4 FOUNDATION AGRICULTURE.WELL OTHER WELL PITS/SUMPS <br /> it INTENDED USE f TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> n Industrial ❑ Open Bottom s „ .0,Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:] Domestic/Private F ❑ Gravel Pack ❑ Tracy-%, Type of Casing_ Specifications <br /> I'1 Public <' CI Other fl Delta'" -Depth of Grout Seal Type of Grout <br /> `V <br /> I I Irrigation _ Approx. Depth I I Eastern­.t ff—Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump // ., 43�'H.F4/ !-- _ _ State Work Done <br /> Well Destruction ❑ Well Diameter f Sealing Material 8 Depth <br /> Depth Filler Material i Depth (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR lADDfTION•F I. .DESTRUCTION I I iNo septic system permitted it public sewer is •x] <br /> available within 200 feet.) t <br /> f Installation will serve:—Resyidence °"C6mmerdial-� 0''Aw.. <br /> Number of living units: ! Number of bedrooms — <br /> Character of soil to a depth of 3 feet: ��R"� Water table depth 1 , <br /> SEPTIC TANK Type/Mfg ' Capacity s No. Compartments <br /> PKG. TREATMENT PLT. 0 i Method of Dispp sal <br /> Distance to nearest: Well+VQ Foundation ^ Property Line �14 <br /> ,/. <br /> j LEACHING LINE No. & Length of lines To al length/size <br /> f 4.FILTER BED 0 Distance to nearest: Well Foundation ) Property Line � b <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin: County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the parformance 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 applicant must call for all required insPections. Complete drawing on reverse side. j �Q <br /> JIA:�tll�]p� N� _ Title: Date: <br /> Signed X (_- <br /> 4 <br /> :SDEPARTMEN T USE ONLY q ••� <br /> L ' - �`\ . kA <br /> Application Accepted by 1 Date Area df." ` c. to •- <br /> Pit or Grout Inspection by Date Final Inspection by Date 73 <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 4 Box 2009, Stkn, CA 85201 <br /> FEE AMOUNT DUE AMOU T REMITTED CAS RECEIVED BY E 1 ERMIT'NO. <br /> j INF / 1 / <br />{` EN 13-24 IR EV.rKW <br />