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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete .in Triplicate) <br /> made to Saa Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is hereby <br /> r application is trade in compliance with San Joaquin County Or <br /> Na. 5I+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. f � <br /> City`, — Lot Size/Acreage <br /> Job Address J <br /> !1� �� I 12 73O I�� LOe�cR �9)C- Phone 7 /L <br /> Owner's Name ` Address R <br /> EE cfXR167 <br /> f� II'. • r •License No _Phone ��' � <br /> Contracftsr�l�!t^ . - Qf Address <br /> TYPE OF WELLIPUMP: i�, "-NEW WELL WELL REPLACEMENT 171 DESTRUCTION ❑ Out or Service Well ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ° SEWER LINES � DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �� AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial °�Open Bottom D Manteca Dia. of Well ExcavationDid: of Well Casing - <br /> Type o! Casin ��f= Specifications Domestic/Private ❑. Gravel Pack El Tracy 9--- <br /> VI Public Cl`Other n Delta Depth of Grout Seal 100 Type of,Grout <br /> I I Irrigation II Approx, Depth I I Eastern Surface Seal Installed by f lls'i <br /> Repair Work Done ❑ Type of Pump dub H.P. State Work Done_ <br /> p k Sealing Material & Depth <br /> Well Destruction ❑ 'Well Diameter <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1_! DESTRUCTION I I INo septic system permitted if public sewer is <br /> �.� { .,: available within 200 feet.l <br /> i Installation will serve: Residence Commercial_ Other { <br /> r. V <br /> Number of living units: Number of bedrooms • •• ••� W <br /> CharaWater table depth <br /> cter of soll to a depth of 3 feet: <br /> SEPTIC TANK ❑I Type/Mfg Capacity No, Compartments <br /> PKG, TREATMENT PLT. ❑I. 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 to nearest: Well Foundation Property Line <br /> A� <br /> SEEPAGE PITS 1 II Depth Size Number <br /> III SUMPS Ll' Distance to nearest: well Foundation Property Line <br /> i w <br /> iii DISPOSAL 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 laws, and <br /> rules and regulations of the San Joaquin County <br /> Homeowner or licensed agent's signature cenifies 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 subcontracting signature <br /> b <br /> f 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 is we of California." I <br /> I <br /> The applica ust c I r till r urred i spactions. Complete drawing on retrewa.7. <br /> i. <br /> Signed X � Title: . o C' " �- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1��2 Area <br /> j <br /> Pit or. ro t Inspection by ` �1/-w Inspection Final Inspeetian by Date <br /> !!! Additional Comments: <br /> I! <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> it 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> i! <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS <br /> FI If RECEIVED BY DATE PERMIT NO. <br /> �(A <br /> EH 19.2 TREY.t r e 5r a-7 �a <br /> EH a"2p <br />