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APPLICATION <br /> SAN _QUIN COUNTY PUBLIC HEALTH IVICES <br /> ENVIRONMENTAL HEALTH DIVISIUM <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 PCZ-ii� ZO-04-7 - + <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 Services. <br /> Job Address ��f7ir ' _t2l­AN City Lot Size/Acreage <br /> Owner's Name No. Address ��� L��a��d2— Phone <br /> Contractori+ddress_ Z� License No. Phone <br /> K�►.I��_ �7��µU21 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 7i DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (0I 'M / <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _`�'� � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tit <br /> F-1, Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing Z <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_�M SL1i t_}.p Specifications <br /> 1'1 Public 1.1 Other n Delta Depth of Grout Seal 3— Type of Grout <br /> I I IrnOauon _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 ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 2W feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Founaation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. / <br /> Signed X Title: STA fEF Date: �1 / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date l 0 Area 3 O '? <br /> Pit or Grout Inspection by e l6 n � Final Inspection by ' <br /> atDate <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services q o <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> CK V <br /> INFO AMOUNT DUE AMOUNT REMITTED rQCASH -RREEC,E�IIVED BY DATE �j 2 P <br /> ERMIT NO. <br /> EH 13-24IAEV.1i145 <br /> EH 14.20 (J <br />