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�t <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <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 <br /> Services. Jp [� <br /> Job Address I� fiifhel ` � ' City Lot Size/Acreage I/Z <br /> y <br /> Owner's Name v� ��+ Address "�• j;�g� � 'Phon <br /> 1/ws e /fJ <br /> Contractorvl'IV� ress �V. " 1 dense No. Phonel��� <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMETr D DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATIO O SYSTEM REPAIR D rFLD' LINE <br /> ell C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAFOUNDATION AGRICULTURE WELL OTHER WUMPS �7INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ! 44C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavationfl Casingi:l Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ ons <br /> I'I Public 1.1 Other D Delta Depth of Grout Sealout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet <br /> Installation wt serve: Residence_ Commercial_ Other <br /> Number of living u Number of bedrooms <br /> Character of soil to a depth oett <br /> SEPTIC TANK O Type/Mfg - <br /> -------Capacity-PKG. TREATMENT PLT. O p+ Y ho i sal <br /> Distance to nearest: ell Foun Pro n 1�,5 <br /> ACti i ri 1 <br /> LEACHING LINE C �.cetohoarest: <br /> f lines Total ikk " <br /> FILTER BED ❑ if_r t l I! :yt I Vir;E <br /> Well Foundation ESV'+'�propertY'i4n'A <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL P NDS ❑ <br /> I hereby certify that I have prepared this appli i,R rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin C iv O <br /> Homo owner or licensed agent's signature s the following: ' ify 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 b etno[ t ompensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the rf rmancavh1bg work r ich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif ia." CERTi =D <br /> The applicant m st call for all re wired ins ti in kRr;ra rte n reverse side. �y <br /> Signed �u , Irwi n %,(ti,A,6a� COY Date: <br /> EPARTM ENT USE ONLY 2 <br /> Application Accepted by Q � Date � C3 Area <br /> Pit or Grout Inspection by Date Final Inspection <br /> ,,byDate <br /> Additional Comments: ` U 'ISMSre V <br /> Applicant - Return all copies to: San Joaquin County Public Health Services \}� n <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CK If CASH RECEIVED BY r DATE/ PERMIT'NO. <br /> EH 3-24(REV.1/"51 �_Ob -661 �� I^ (3 �I DO y)�Q <br /> EH 1bTe w`� tl/ L l! <br />