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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC 11MALTH 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 ;n Trip)icate) f <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This f <br /> application is made in compllanee with San Jasquin County Ordinance No. 549 and 1862 aid the Rule.: azd Regulations of Baa � <br /> Joaquin County Public Health Services. <br /> Joh Address �11�_�r+V'g� City �.4_ Lot Slxe/Acre.ge r� <br /> Owrw's Name {"t Address Sri Phone _ <br /> Contractor r111k� 1'c/l/1� Aeeress_P�_�by �$O License No.( Pnone 937-7775 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR L7 OTHER 0 Monitoring Well O <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 /> D Industrial 0 Open Bottom 0 Manteca Du of Well Excavation Dia.of Well Casing <br /> r1 Domestic/Private D Gravel Pack 0 Tracy Type of Casino _— Specifications <br /> 1.1 Public Ll Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I W.Jetron __Approx.Depth I I Eastern Surface Seal Installed by <br /> R+pair Work Done 0 Type of Pump H P. Sure Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Notarial i Depth , <br /> Depth Filler Material A Depth f� <br /> TYPE OF SEPTIC WORK; NEW INSTAI LATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted of public sewer e <br /> available within 200 feet.) <br /> serC <br /> Installation Mill —: Residence� rr <br /> Co .mwcyl Other_ 1 \QtD LIQ n ��j <br /> Numbw of living urats: I Number of bedrooms lt3 <br /> Chwavt,or soil to a depth of]feet: ,gcl k"_ Water table depth <br /> SEPTIC TANK Type/Mfg tnnc,C'--FL Capacity l)::5 1_ No.Compartrtrnts <br /> PKG.TREATMENT PLT.D / Method of Disposal <br /> Distance to nearest: Well coundetion Property Line '-I <br /> LEACHING LINE V'o.8 Length of Imes 'D.. - Qn Total length/sue <br /> FILTER BED ❑ Distsnce to nearest. Wellr <br /> �K n r Foundation�._ Property Line 3 O <br /> SEEPAGE PITS 11f Deprn _ SireN4mber Q. <br /> SUMPS LI Distance to nearest: Well f N0 Foundation_�� Property Line .3h <br /> DISPOSAL PONDS D <br /> I hereby unify that I have prepared this application and that the work will be done in accordance,+nth San Joaquin county ordinances,state laws,and <br /> rules and ragularions of the San Joaquin County <br /> Home owner or licensed agent's signat,ue comfort the following:-I comfy that in the performance of the work for which this perirvt is iaaued,I shag not <br /> employ any person tin such manna as to become subject to workman a compensation laws of California."Contractor's hang or subcontracting signature <br /> candles the following:"I certify that in the performance of the work for which this permit is iuued,I s1.Hl employ persons subject to workman's comply sa• <br /> tion laws of Ccuifonis." <br /> The applicant must call far all ro/gq��uwed nspectlom. Complete dtawtng on reverse side. <br /> Signed X //4i�� li-tnf�.C/ Title: f7 IvvT..�!` Data: V�TI <br /> FlPARTMENT USE ONLY <br /> I. i <br /> Application Accepted by �G lila pm,,.aa S Dau .item <br /> � � / 's or Grout Inspection by �wY,1.,,��1 Dau Z� —iFinN Inspection by i�J M� Dem <br /> Additional Comments: i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> EovirontnentalW.a.lth Permit/Services <br /> 445 N San Joaquin, P O Bo■ 2009, Stkn, CA 95201 <br /> FEE <br /> I lFO AMGUNT DUE .'MOUNT REMITTED I CASH RECEIVED BY DATEQ PrI pt No. <br /> .Etr 13:r laev.rr,sr n1 •00 <br />