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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT =IRES 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 So. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> "'' Job Address ___r.__ —_ Y f�_ o City Lot Size/Acreage .. <br /> Q <br /> Owner's Name dress -- S • Phone / <br /> 7. <br /> Contractor s ansa No. Phone <br /> D <br /> TYPE OF W E L Cl NEW WELL WELL REPLACEMENT Cl DESTRUCTION D Out of Service We11 ❑ <br /> PUMP INSTALLATION Ci SYSTEM REPAIR Ll f OTHER ❑ Monitoring Well U {l <br /> DIS`:ANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation r Dia. of Well Casing �,? <br /> f.l Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing_ f Specifications r ' <br /> I'l Public f-1 Other f1 Delta Depth of Grout Seal Type of Grout <br /> 11 Ifnuation __Apnrox. Depth I I Eastern Surface Seal Installed by f - <br /> Repair Work Done Ll Type of Pump H.P. .,State Work Done <br /> Well Destruction [I Well Diameter Staling Material Dep'th.;r s <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I : DESTROCTION I 1 (No septic system permitted if public sewer is <br /> � available within 200 feet.) i <br /> Installation will serve: Residence _.. Commercial Other W� h"� <br /> Number of living units: Number of bedrooms t <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> + t P <br /> SEPTIC TANK O Type/Mfg I '- V I Capacity ' Q No. Compartments <br /> PKG. TREATMENT PLT. ❑ t ni R Method of Disposal <br /> lDistance to nearest: Well Foundation -�— `— Property Line ~r <br /> LEACHING LINE ❑ No. & Length ol.lines` s �--�' ' 16 Total length/size <br /> :FILTER BED 0 Distance to nearest: ,Well _ Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Oepth Size IN mber <br /> SUMPS Ll Distance to nearest: Well . FQ Foundation Property Line <br /> DISPOSAL PONDS O ! <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County t -• <br /> Home owner or licensed agent's signature certifies the fcllowing:_;l certity that in the performance of the work for which this permit is issued, I shall not <br /> employ any peraon in such manner as to become subject-to woikman's compensation-laws of,Ca0fomia."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 shalt employ persona subject to workman's compensa- <br /> tion Isws of California." <br /> IThe applicant must call for all re . ed in pe io S. Complete dra on reverse side. <br /> i 1 'Signed T;��- <br /> LY <br /> . C, ^►Appticetion Accepted by Date -� r { Area � ��-Z-�� <br /> Lit r Grout Inspection by ! at, Final lns'ectien by?� Doted" < <br /> Add tionaf Comments: I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTEO CK RECEIVED BY GATE PERMIT'NO. <br /> INFO <br /> r /` CASH C� nn ]/-'I <br /> . EH 13-24 1!1FV.I/h�r A,1 f Q� / / t-�T U � 3- C.. <br /> F H 14-20 1 V 1 fff ���-- c t�'J <br />