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r �'"� APPLICATION <br /> � l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, 'PRONE (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 worst herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5h9 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public-Realth Ser ces. <br /> Job Address �` / City � Lot Size/Acreage <br /> ! )(Owner's Name ./r d i ' ?� Address ! f�ltw' 7 f•� l�fly� Phone f�dj r fij <br /> )(Contractor. Address ' License No. Phone' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well G1 <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER O Monitoring well El <br /> DISTANCE TO NEAREST: SEPTIC TANK SE LINES DI AL FLD. PROP. UNE <br /> i <br /> FOUNDATION AGRICU URE WEL t OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C `UCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Ia.,o ell Excavation Dia. of Well Casing <br /> C 1 Domestic/Private Gl Grave) Pack L7 Tracy Type of Ca <br /> r I g— Specifications <br /> i'I Public Cl Other C� a Depth ofr Grout Gal Type of Grout <br /> 111niUalion Approx. Dep 1 1 Eastern Surface Saul Install by <br /> Repair Work Done L7 Type of Pu H.P. to Work Done <br /> Well Destruction ❑ Well Di eter Sealing Material'� Depth <br /> Depth Filler Fla al & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITIO ESTRUC71ON l I INo septic system permitted if public sewer is <br /> I <br /> available within 200 feet.) <br /> Installation will serve: Residence le, <br /> ,� Commercial..,,, Other G <br /> I Number of living units; Number o_f bedrooms_ � ++^� W i �t V. S ,Ay%a <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK � Type/Mfg w w Capacity - a)_ <br /> No. Compartments <br />{ PKG. TREATMENT PLT. Cl <br /> W4, Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE D No. & Length of lines _Q X15 1 Total length/size <br /> FILTER BED C7 Distance to nearest: Well Foundation i Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br />` SUMPS �,�;w� LI Distance to nearest: Well Foundation Property Line <br />� DISPOSAL PONDS CJ <br /> hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;state lays, and <br />• rules and regulations of the San Joaquin county <br /> Home owner r Ii In d agent's aignature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shat)not <br /> employ any rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the llowi g: " certify that i the performance of the work for which this permit is issued, I shall employ persons subject to workman's campansa <br /> tion laws of Calif nls.„ <br /> i f <br />' The applic t call r e inspections Complete drawing on reMm <br /> ide. <br /> Y Si ned l ` i <br /> I'\_ g Title: � Dater <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by Date __ L`rtl ]{ Area <br /> Pit or Grout Inspection by ___ Date .Final Inspection by <br /> Additional Comments: I <br /> Applicant - Return all copies to: tSan Joaquin.County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, SEkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK AEC I <br /> VED BY <br /> l <br /> , INFO CASH DATE PERMIT'NO. <br /> EH 15-24 IS EV.1 i N 51 A- <br /> [/'�� <br />