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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3424 i <br /> P O BOX 2009, STOCKTON, CA 95201 1 <br /> PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED <br /> { (Complete in Triplicate) <br /> Application is hereby made to San'Joaquia County for a permit to construct and/or install the work herein described. This r <br /> application is made in Compliance with San Joaquin county Ordinance Ho: 51+9 and 1862 and the Rules and Regulati one of San <br /> Joaquin County Public Health Services. f'9 <br /> 5 Ot- [i G City Lot Size/Acreage /ie• SGS <br /> Job Address te�rr[[ <br /> Address �je� LL ZJed Phon< <br /> Owner's Name /_ r'J C 4 <br /> I <br /> Conttactot` IL-Address ' - License No. 4l4l�-� Phon <br /> TYPE OF WELLIPUMP: NEW WELL D'-b&f� WELL REPLACEMENT ❑ DESTRUCTION Cl Out of service Well Gl <br /> / R Monitoring Nell j <br /> PUM,PJVL ❑ SYSTEM REPAIR ❑ OTHER bari"'i + k - ; <br /> DISTANCE 7O NEAREST: SEPTIC TANK S E LI ES 10�t - D15`1Q A! F_10-'Z40"_ PROP. LINE' vU <br /> FOUNDATION rrla A L %E WELL OTHE PITS/SUMPS r i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> [-I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ('7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public <br /> �Olher fl Delta Depth of Grout Seal Type of GroutLP <br /> 11 Irrigation ��Q...Approx: Depth I I Eastern Surface Seal Installed by,.�. <br /> Repair Work Done 0 Type of Pump H.P. State Of Done <br /> Well Destruction ❑ Well Diameter - i s. Scaling Material & Depth d j <br /> Depth T Z9 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR1ADDITION I I DESTRUCTION I'I INo septi system <br /> m feert'ed if public sewer is <br /> availabInstallation will serve:- Residence Commercial— 'Othef <br /> Number of living units: Number of bedrooms <br /> Character of soil,to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> C1 Method of Disposal <br /> PKG. TREATMENT PLT. <br /> a <br /> Distanceto nearest: Well Foundation Property Line <br /> .1. .� <br /> f <br />! LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> F SUMPS Ll Distance to nearest: Well Foundation Property Line t' <br /> I DISPOSAL PONDS 0 r <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 <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 personin such manner as to become subject to workman's compensation laws of CaMornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cartify 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 st call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> AOR DEPARTMENT USE ONLY <br /> Application Accepted by .Date - l�- Area <br /> Pit or Grout Inspection by4W 2 <br /> Date Final Inspection by �-- Data <br /> Additional Comments: ' <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 /> L- <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> r <br /> INFO R q ems{ //)]///1 <br /> . EHSS-24{REV.I'm 51 $�r�a {''�-0 'f �_0` <br /> EH 14.20 <br />