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��Cj SS APPLICATION "i <br /> J <br /> mozo-QUIN COUNTY PUBLIC HEALTH SERVICES <br /> 07 ENVIRONMENTAL HEALTH DIVISION k <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ai�1~ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) * <br /> 1�, G <br />- Appli 'n is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> s ion is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ) <br /> in County Public Health Services. j <br /> ass p <br /> Job Address r '�/ r " � y City '��`� `fit Size/Acreage <br /> Owner's Name Address ,`fi✓ Phone <br /> Contractor " "'�' Addr Zj ,:.� License No. .��LI y�� Phone 21 -6 L—/L 6 k <br /> TYPE OF WELL/PUMP: NEW WELL 2 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S��REDISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1D /.� c Dia. of Well Casing -� ! <br /> C1 Domestic/Private ® Gravel Pack n Tracy Type of Casing _Lc P_IVC Specifications <br /> [1 Public EQ Other 1­1 Delta Depth of Grout Seal Type of Grout ,,_4 W141, <br /> I i I(rigalion 7_5 Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Seeling Material 8 Depth pn tt; <br /> X Depth 7 S ' . Filler Material & Depth AZZA <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other n <br /> Number of living units: Number of bedrooms " <br /> Character of soil to a depth of 3 feet: Water table depth (� <br /> 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 ❑ No. & Length of lines f Total length/size <br /> FILTER BED R Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 thepsrf, Tf _t <br /> employ any person in such manner as to become subject to workman's compensation laws o e r o i e <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I i man s compensa- <br /> tion laws of California." SPECIAL. PERMIT <br /> applicant must call for all required inspections. Complete <br /> /drawing on never <br /> Signed X. tift:: Date: <br /> } <br /> OR DEPARTMENT USE ONLY � <br /> Application Accepted by q, Date �Y Area <br /> Pit or Grout Inspection by L '� C Di/f/, Final tnspec 'on by Da 2— <br /> Additional <br /> Additional Comments: r <br /> Applicant - Return all copies to: San Joaquin C my Puirmit/Services <br /> c Health Services <br /> ll ,I Environmental Health I <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201. J <br /> IF FO AMOUNT DUE AMOUNT REMITTED CA5 RECEIVED By DATE PERMIT'NO. <br /> • EH 1124(REV.i i n 51 �Z 9z - <br /> EH 14.26 / ✓ ✓ <br />