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I APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> k P 0 BOX 2009, STOCKTON, CA 95201 <br /> if .w <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f (Complete in Triplicate) <br /> i 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 /> e Job Address _1,,34-' 71 City.__ZAt4C%A/Lot Size/Acreage <br /> Owner's Name JA 414 Y Address -SA k1'`1 Iii Phone <br /> Contractor t:L " r� L& :~. ` dress - i nse no. D�� Phone c�S -I <br /> TYPE OF WELL/PUMP: NEW WELL'❑ WELL REPLACE=MENT 171 DESTRUCTION D Out of Service Well ❑ <br />' PUMP jNSTA'LLATION 13 SYSTEM REPAIR 0 OTHER"❑.. Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> n Industrial ❑ Ope4 Bottom ❑ Manteca Dia!of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> I'I Public (:) Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ii Irrigation r Approx. Depth I I Eastern Surface Seal Installed by <br /> r <br /> Repair Work Done ❑ Type of:Pump H.P. I -__ State Work Done <br /> Well Destruction ❑ Well Diametert - * Sealing Matf erial & Depth <br /> Depth 1 Filler Materiel 8 Depth R <br /> TYPE OF SEPTIC WORK; NEW INSTAL LATION �1�-f I REPAIR/ADDITION STRUCTION l I INo sepl.ic system permitted it public sewer is <br /> available within 200 fest.l <br /> Re <br /> Installation will serve: 'dance t--�tornmercial — Other ` <br /> Number of living units: �. 'lN-u-m—be-r�of-bed ms <br /> Character of soil to a depth of 3 feet: ' r" Water-table Aepth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TRE Method PLT:❑ � Method of Disposal. <br /> : Distance I nearest: Well Foundation Property Line <br /> LEACHING LINE �dr Length of tines Total length/size• i <br /> FILTER BED ❑ Distance to nearest. Well ... Foundation Propeny Line <br /> I <br /> SEEPAGE PITS Itl '-Depth Size Number f �^ <br /> SUMPS LI Distance to nearest: Well -- Foundation Property Line <br /> { <br /> DISPOSAL PONDS ❑ 1 r <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 t <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 workmen's compensation laws'ot California." Contractor's hiring or sub-contracting signature <br /> certifies t following: 'I certify that in the.pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> ` do laws alifoml . -, • <br /> r ; T e appiiea t at a 11 f al tio1 mplete drawing on averse sda. <br /> �a •'Signe = Title: <br /> r r FOR DEPARTMENT USE ONLY <br /> _ ,Application.Accepted_by f - _date. ~/� Area. ^c�* <br /> T - - _ <br /> Pit or Grout Inspection by _ Data Final Inspection by Dots <br /> Additional Comments: ��x✓ n, h'tit R� Ah.�6� i r a> y <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Env i-ronmental-Heahtfi Permit/Sereices•--+-•�-�lctvr tu4uW-Ce*A4d. -; <br /> 445 N SanAJoaquin; O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUF REMITTED CASH CEIV BY 9ATE PER MI7'NO. <br />` <br /> EH <br /> 14-26 JJ <br /> i <br />