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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> _ ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 20091 STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or inataU the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance,21o. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I�f gyp,/' <br /> Job Address i JLi'[� City Lot Size/Acreage ~ r,y �"+r <br /> Owner s Name Addresses 'O• ! one <br /> Contractor`&kerwrmuk ' ,ess 0I• r ' r rCEnse No Phonehy r <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEME C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ 0 HER a ell ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK _ SEWER LINES DISPOSAL FLO LINE <br /> FOUNDATION AGRICULTURE WEL OTHER W PIT /,S MPS +7An`-,� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC IONS P !sI <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation f Dia ffWell Casing <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I 1 Public CI Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____Approx Depth l I Eastern Surface Saul Installed by <br /> Repan Work Done ❑ Type of Pump H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing lYtaterial 46 Depth <br /> Depth Filler Haterial li Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 240 feet.} <br /> Installation will-serve Residence____. Commercial— Other <br /> Number of living unr Number of bedrooms <br /> Character of soil to a depth o! <br /> SEPTIC TANK ❑ Typo/Mfg Capacity >r�IIrCID <br /> PKG TREATMENT PLT ❑ PTl.vL o tli:pc�sal <br /> Distance to nearest, !Well Founda Propeoj <br /> AAL ^ frlJTY <br /> LEACHING LINE ❑ No kX figtb of lines Total EMI_-fH AEWICES <br /> FILTER BED ❑ iStaanca to nearest Well Foundation EN14iF1A1 grub 'JII L,ri .1� l.; <br /> SEEPAGE PITSI 1 Depth Sue Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this appli +Q rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Q <br /> Home owner or licensed agent's signature the following ify that in the performance of the work for which this permit is issued, I shall nor <br /> employ any person in such manner as to Je��o«t ompensatron laws of California Contractoes hiring or sub-contracting signature <br /> certifies the following "1 cam that m the rmanclfo0ft work r ich this permit is issued, I shall employ persons subject to workman's compansa <br /> tion laws of Calif CERTr-,'m <br /> r 5 — i"l <br /> The applicant st call for all utred t Gra rte reverse side <br /> as �f_ p <br /> Signed �� ��LJlec�JL-N , �--IJACea� r� Date �/� <br /> DEPARTMENT USE ONLY <br /> Application Accepted by / i Data i <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> �ditional Comments <br /> Applicant - Return all copies to San Joaquin County Public health Services <br /> Environmental Health Permit/Services j <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE <br /> INFO MOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY GATE PERMIT NO <br /> EH 13-24(REV 1/1131 i` 1 1 I 1-77 <br /> EH 1426 I s _ <br />