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APPLICATION <br /> I, <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 with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> City ✓ Nt Size/Acreage <br /> yJob Address fi�rj, !� <br /> Owner's Name f <br /> n ddress _ i E _ _ Phone oz <br /> I, )(Contractor <br /> -"E Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT L] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well L7 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> f7 industrial C3 Open Bottom 0 Manteca¢ - Dia. of Well Excavation <br /> Specifications <br /> C] Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing_ Type of Grout <br /> 11 Public Cl Other 11 Delta Depth of Grout.Seal <br /> t I Irrigation Approx. Depth ll Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done , <br /> Sealing Material & Depth <br /> i Well Destruction ❑ Well Diameter <br /> Depth Filler Material & Depth <br /> permi_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION (Nailsepttic system <br /> m feet ted it public sewer is <br /> I <br /> Installation will serve: Residence — Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Charscier of soil to a depth of 3 feet: Water table depth <br /> 5 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth = Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that.the wiork 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 /> l 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." w <br /> The applican all for alt required inspections. Complete drawing on reverse side. <br /> igned �- Title: _ - - <br /> AllZe <br /> Date: <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by <br /> Date, Area <br /> l Pit or Grout Inspection by Date Final Inspection by Date <br /> I Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Hpalth Services <br /> k Environmental Health Permit/Services <br /> 445 N San Joaquin, p 0 Box 2009, .Stkn, CA 95201 <br /> ( FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. <br /> Ik INFO CASH <br /> x S <br /> E„17.2 lQ� `7 r� JL4 LA--a�= <br /> . wEv.i i n sl <br /> " EH 14,26 <br />