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APPLICATION <br />L <br />SAIV JUAQUIIN COUNTY PUBLIC HEALTH SERV C'�_',i <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 trade 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 Re lations of San _ <br />Joaquin County Public Health Services� �� 0" ��C�—�yO1,rS��j—(� <br />I.nt Size/Acreage L l.t i A l� 'T4 <br />i 11 iam'xe i-�Address In <br />` �t 3� <br />Owner's Name <br />`v '� Phone <br />CIN <br />RECEIVED BY <br />1'C%��� <br />address 2 L cense No. S14h� Phone�`(T <br />Contractor <br />TYPE OF WELL/PUMP <br />NEW WELL O WELL REPLACEMENT i DESTRUCTION ❑ Out of Service Well ❑ <br />PUMP INSTALLATION G SYSTEM REPAIR OTHER ❑ W Monitoring Well <br />Al <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE <br />!-1 <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />O Open Bottom ❑Manteca Dia. of Well Excavation � Dia. of Well Casing <br />Indu�;trtal <br />F] Domestic/ Private <br />Tracy Type of Casing_ l._ Specifications <br />❑ Gravel Pack Llv <br />I'1 Public <br />t <br />I1 Other 1-1 Delta Depth of Grout Seal Ty/ple,of Grout <br />I I Irrigation <br />__ Approx. Depth I I Eastern Surface Sedl Installed by _ ?-,P- fl:A/u <br />Reoair Work Done LJ <br />Type of Pump H. P. State Work Done <br />Well Destruction O <br />Well Diameter _ Sealing Material 3 Depth _M <br />Depth Filler Material & Depth <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Instal on will serve: <br />Residence Commercial _ Other <br />Number of It ,. units: <br />__ Number of bedrooms <br />Character of soil to <br />th of 3 feet: —_ �� `Water tHble depth <br />SEPTIC TANK <br />❑ y __ _ C'apacit _._ Nc. Compartments <br />?KG. ''REATMENT PLT. <br />❑ Method n1 Disposal <br />Distance to nearest: bVet Foundation Property Line <br />--- <br />LEACHING LINE <br />— -- <br />�� Total length/size_ -I <br />Cl No.�new <br />FILTER BED <br />❑ DisWell Founcauon Property Line <br />SEEPAGE PITS <br />I Depth Size Number <br />SUMPS <br />LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL NDS <br />❑ j <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 />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 law lifornia." <br />Thea licant ust call fpr all requyed �pspections. Complete drawing on reverse side. <br />Signed \IZ44 Title: � • Date: <br />Sp - _ FOR DEPARTMENT USE ONLY <br />Application Accepted by <br />Pit or Grout Inspection by <br />Additional Comments: <br />Date Area <br />Date Final Inspection by <br />Date <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services �_ 9 i O 1 <br />445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br />EH 13-241AEV. iir 5) <br />EH 14.20 <br />FEE <br />NFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH CK <br />RECEIVED BY <br />DATE <br />PERMIT NO. <br />IN <br />C <br />