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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f. ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby de to $a Joaquin county for a permit to construct and/or install the work herein described. This <br /> ma <br /> e with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in compliance <br /> Joaquin county Public Health Services. /� <br /> G Lot Size/Acreage �< n�A <br /> City w <br /> Job Address f <br /> Owner's Name �' sr3 Address <br /> Phone �j � -���� <br /> 60 <br /> Contractor Address <br /> 3�,�4t) License No. Phone ��Iz b <br /> DESTRUCTION D out of Service Well <br /> TYPE OF WELLlPUMP: NEW WELL 11 WELL REPLACEMENT C7 D ❑ <br /> OTHER ED Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> . DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia-of-Well Excavation ry — - s <br /> ' Type of Casing_ Specifications <br /> 1;-1 Domestic/Private ❑ G`ravel Pack ❑ Tracy � Type-of Grout Q, <br /> Il Public 1-1 Other n Delta Depth of Grout Seal \� <br /> I i Irrigation — Approx. Depth I I Eastern Surface Seal Installed by \\\\ <br /> of Pump H.P. State Work Done <br /> Repair Work Dane U Type I Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Mater al & Depth ' <br /> { Depth <br /> TYPE OF SEPTIC WORK: NEW IN TA LATION 1 1 REPAIR IADDITION I DESTRUCTION.1 1 available seotic.sy t 200 permitted if public sewer is <br /> Installation will servei,,ReIsi encs 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 Type/Mfg a 'mow pacity No. Compartments <br /> C PKG. TREATMENT PLT. ❑ of Disposal <br /> Distance to nearest: Well Foundation' Property Line <br /> V. <br /> LEACHING LINE i� No. & Length of lines ` Total length/size <br /> r /Foundation.S"Gs f _ A6 r_ Property Line )p <br /> k FILTER BED (] Distance to nearest: Wall.. <br /> SEEPAGE PITS I I Depth —Size Q Number <br /> ,� ' To '.� P ` <br /> SUMPS `Distance to nearest: Well+--- -�- -Foundation� .wroperty Line D <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application ander at the work will be done in accordance.with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County �*s <br /> Home owner or licensed agent's signature certifies the following: "i certify that in the-periormance 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,'l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c r all re ired insPection&. Complete'drawing on reverse side. ^+. <br /> ti <br /> oe Date: <br /> Signed Title: <br /> 110/ <br /> FOR DEPARTMENTUSEONLY <br /> Application Accepted by <br /> n.� ��. - Data + ,Area Z f "f <br /> Pit or Grout Inspection by <br /> Date_,Final Inspection by Data `f c1.3 <br /> Additional Comments: <br /> ° Applicant'- Return all c pies taF°'Sari Joaqun`Coilnfy Public Health Services <br /> t Environmental Health Permit/Services <br /> 445 N San l,oaquin.,, P O Box, 2009, Stkn, CA-95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO -7 <br /> . EM 13-24IREV.IiHSI �� c0� Zq S1aj �� �_ �� <br /> EM 14-n <br />