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APPLICATION <br />FSR # <br />SAN JOAQUIN COUNTY PUBLIC HEALTH 1SV,I <br />$RCSS <br />ENVIEOMLENTAL HEALTH DIVISI R� {� <br />445 N SAN JOAQUIN, PHONE (209)4 <br />P 0 BOX 2009, STOCKTON, CA 9 v <br />(Complete in Triplicate) <br />Application is hereby aade,to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application to made in compllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Size/Acreage <br />Job Address C Ty <br />AQ JU 16 J—� Phone <br />Owner's Name ,1 5 Address _ <br />r�rr�� <br />COnIraCIOr 6GCG��. Address //L� , A7 �{.1�License rr '�.7t•S�'r� Phone <br />TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT F1 DESTRUCTION r, Out of Service Well 0 <br />PUMP INSTALLATION C SYSTEM REPAIR C1 OTHER O Monitoring 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 />Ll industrial 0 Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing <br />Cl Domestic/ Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br />f , <br />['1 Pltblic 1-1 Other f] Delta Depth of Grout Seti PAYNT <br />I I Irrigation — Approx. Depth I I Eastern Surface Seal Instilled by <br />Repair Work Done 0 Type of Pump H, P. __..— Stat+ Work Done , RECEIVED <br />Well Destruction 0 Welt Diameter Sealing Material 1 Depth 111 K '? Z 1"4 <br />Depth Filler Material i Depth OuNTi <br />1;AI9 if <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI TION >< DESTRUCTION I INo saptlQ <br />availat�� t�ly�4i►H Dl1r1S1 � <br />Installation will serve: Residence A� Commercial — Ott,er �_ <br />Number of living units: _� Number of bedrooms <br />Character of sod to a depth of 3 feet: ::AAJPV Water table depth <br />SEPTIC TANK p Type/Mfg CapecilY No. Compartments <br />PKG. TREATMENT PLT. 0 Method of Disposal <br />Distance to nearest: Well . _ Foundation Property Line <br />LEACHING LINE No. 3 Length of lines'_ �f��(.,�, !� F7—itwal length/size <br />FILTER BED 0 Distance to nearest: Well w�— Founoatron 352 Property line ,d;�n <br />J _ <br />SEEPAGE PITS 11 Depth Size % % N mu�bar . _ <br />SUMPS Distance to rwarest: Well ri.' Foundaiion ML+-� ' ,-Fmpaty LinaZ!5 a- <br />DISPOSAL PONDS 0 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San .ioaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin County <br />Home owner or licensed aWl's signature candies the following: "I certify that 1n the performance of the work for which this permit is issued. I shell not <br />employ any person in such manna; as to become subject to workman's compensation laws of California," Contractor's hiring or Bub -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 ell fjp3o inspections. Complete drawing on reverse side. <br />Signed x Title: _ Dater p� <br />FOR DEPARTMENT USE ONLY <br />Application Accrtpted by Date res <br />Pit or Grout Inspection by Date Final Inspection Date <br />Addnionai Comments: <br />AVFlic,ant - Return all copies to: San Joaquin County Public Health Services <br />y Environmental Health Permit/Services <br />4�r495 N San Joaquin, P O Box 2009, Stkn, CA 9 O1 S V V <br />• EM 13.74 IrIEV. I I K 5 <br />EH 147! <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />K H <br />RECEIVED BY <br />DATE <br />.o-, <br />11 , <br />e <br />