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APPLICATION G,A <br /> SAN JenQUIN COUNTY PUBLIC HEALTH J: IVICES ,gam yF <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 c� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 9, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID F T <br /> (Complete in Triplicate) EJ�j <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This <br /> Y <br /> application in made in complisnce with San Joaquin County Ordlnmce No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / PR <br /> C <br /> Job Address 75 W'y '� 7 r� ^017 v IV I) City / bZkf1i,1 Lot Size/Acreage <br /> Owner's Name �' l/ sol 6 Address 9,1`7-7_ Phone 7Z 6Mq <br /> i <br /> Contractor address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 'NELL REPLACEMENT r DESTRUCTION X Out of Service well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Nonitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> .'i Public (-I Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done J Type of Pump H.P. Stat Work,,QQoneeia - _ ,.me,f L5 ]Oy <br /> Sealing Material A Depth <br /> Well Destruction X Well Diameter <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION i I REPAIRiADOITION DESTRUCTION I i (No septic system permitted d public sawar is <br /> available within 200 feet.) <br /> Installation will pits: Residence _ Commercial_ Cther <br /> Number of living units: _ Number of bedrooms <br /> Character of and to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method o1 Disposer <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. g Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size Number 1 <br /> SUMPS LI Dwane to nearest: Wall Foundation Property Line <br /> DISPOSAL PONDS C <br /> I hereby certify that 1 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 comity 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-conttacltng 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 f 11r qiud inspections. Complete drawing on re rig side. <br /> Signed X Till 0.4Dater <br /> FOR DE PA Ill 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 O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> Page 13.4 <br /> EH 1174 IREV,iia si <br /> EH tk.al <br />