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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 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t <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 coaipliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r/ j <br /> Lot Size/Acreage <br /> J' <br /> Job Address - � C�ty�,� <br /> Phone u <br /> Owner's Name dress 41�1 , <br /> 4116, 1 <br /> Contractor, s4ea ansa No. Phone <br /> AW4!v <br /> TYPE OF WET / NEW WELL IFJ WELL REPLACEMENT R DESTRUCTION D Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 1 OTHER ❑ Mcnitoring 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 /> Cl Industrie) d Open Bottom D Manteca Dia. of Well Excavation ' Dia. o/Well Casing <br /> l..'. <br /> F.1 Domestic/Private D Gravel Peck 1-1 Tracy Type of Casing_ f Specifications r <br /> I'l Public S-I Other it Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastem Surface Seal installed by t <br /> , <br /> Repair Work Done D Type of Pump H.P. i -State Work Done <br /> Sealing Material & Depth; i <br /> Well Destruction D Well Diameter r <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I , DESTRUCTION 1 1 INo septic system permitted if public sewer is <br /> �/ � available within 200 feet.! <br /> Installation will serve: Residence—.. Commercial tither Et; � <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK U Type/Mfg ¢ Capacity !' Q No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> iDistance to nearest: Well Founderion-C�� Property Line <br /> ` LEACHING LINE Cl No. & Length of.lines Total length/size <br /> 4.FILTER BED CI Distance to nearest: Well 164Foundation Property Line rQ <br /> SEEPAGE PITS I I Depth Size �r..nd.l*n <br /> �N mbar ,ems <br /> SUMPS LI Distance to nearest: Wellja� s�� Property Line <br /> DISPOSAL PONDS O <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 I <br /> Home owner or licensed agent's iignalure certifies the following'..1 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 su6ject-to woArnan's compensation laws of,Califomia." Contractor's hiring or subconifacting signature <br /> certifies.the following: "I certify that in the periormance'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 mu t call for all re ad in Pe io S. Complete dra on reverse side. <br /> i I i <br /> Signed ills: Dale: <br /> f � <br /> FOR�ARTPAARTMENT SE ONLY <br /> Application Accepted by l 1 _ Date -7—Z Area Z N <br /> 1 <br /> Pit Grout Inspection by� at ==��f� Final Inspection <br /> Gpi IAdditional Comments: IrIII <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMII'NO. <br /> INFO t CASH <br /> fH f� / <br /> EH 14.20(REV.1 n Ol f e Q� 7 f ^� 19 3^ [,� /J <br /> E H t 1.Ie 1 c d'J �--�r , <br />