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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />.ENVIRONXENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P O BOX 2009, STOCKTON, CA 95201 <br />JUEPiu_2 YE OM TE I M) <br />(Complete in Triplicate) <br />Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work b**#Sf1 tS eeribed. This <br />application is moue in ccaV:lunct vlth Sart Joaquin Co=ty Ordinance No. 5L5 and 1862 and the Rules wti!ll lltions of San <br />Joaquin County Public Health Services, <br />N <br />Joh Address rd 4yrq i & City Mlgi4nW� 1t Leat S1 ze/Acreage T� <br />Owner's Name &1 ,0A He Address Phone <br />K <br />Contractor ,.�r�' <br />Address J� J.... License No. _ _ Pt,one5 ins�� <br />TYPE OF WELL, PUMP. 11 NEW WELL WELL REPLACEMENT -1 DESTRUCTION�D OUT of Service well <br />PJMP INSTALLATION O SYSTEM REPAIR L. OTHER C] Monitoring Well L� <br />DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES -,,.-_ DISPOSAL FLO. PROP. LINE <br />FOUNDATION AGRICULTURE: WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL --PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />L1 Industrial0 Open Bottom 0 Manteca Dia of Well`Extai i_tian – i Dia: of tiJi+et! Casir►g <br />DomasticlP.rivate� C1 Gravai Pack* ID Tracy Type of Casing.._ Specifications <br />"i Public t`; QIh6r <br />41 Delta Depth of Grout Seal Type of Grout {� <br />Irrigetiar+ __ Approx. Depth - Ii Eastern Surface Seal Installed by L <br />Repair Work Done e Type of Pump �` � <br />H,P. State Wank Dane _ <br />Well Destruct on 0) Well Diameter Sealing Material i Depth <br />Depth 3i riller Material a Depth '_ <br />NEW,INS�ALLATICIN I I REPAIRIAODiTION I DESTRUCTION I lNo Septic systam permitted it public sower is <br />1 .10 available within 200 feet.) <br />Inatalletian to III serve: Residence -Cornmercial _ Other <br />Number at living urt.ts: .— i, Number of bedrooms <br />Character of SON to a depth of 3 feet., Water table depth <br />SEPTIC TANK T Jlti! ;j"T/L %�tm�r <br />� ype g ._..._ . Capacizy� No. Corttpertrrea'tt$ <br />PKG. TREATMENT PLT. D � �r Method of Disposal <br />Distance to nearest; Well Foundation Property Line <br />,rt <br />LEACHING LINE );Y No."& Length-ol linw$ ti s Total tengthisize— <br />FILTER BED Ci Distance to nes4z' : Well S_� Foundation IrPI x. 11 <br />Property line lv' r- <br />- - <br />SEEPAGE PITS i i Depih S f Sire +� �� _ Number f <br />SUMPS <br />DietBnca to neatest; L Well Se' -,F foundation __.:.lam �'Piapasrty liar . Oe '01 <br />_ <br />DISPOSAL PONDS 0 `y <br />I hereby certify that I hewn prepared this application and that the work WWII be done in accordance VAth San Joaquin county ordinancas, state laws, and <br />rules and t0gutations of the San Joaquin County <br />Horne owner or litenaed agent's signature cettifies-the !oliowirag; " i certify that in the per}ormance of the work lot which this permit is issued, f she not <br />employ any person in such manner as to become subject to workman's compensation IaJvij of California." Contractor's hiring or sub�contracling signature <br />certifies the fallowing; "I certify that in the performance of the work for which this permit is issued, I $hail employ persona subject to work mah'$ componse- <br />tion taws of California." <br />The appiiCant I call for irk repyfired inspections. Complete drawing on reverse tide, y <br />Signed X_rtie: 9 <br />' T _ �h�.y�" 2— <br />C _ � " 3 i <br />l . <br />)R EPARTMENT USE ONLY 1 <br />Application Accaptad byKI►ao`.r • s...A ir�J�rv�1� Data ^9 D ` Area <br />l <br />Pit or Grout Inspection by Data Final Inspection <br />Addrtional Comments: ! �� <br />app;lcant _, Return all copies to; San Joaquin County Public Hcalth Services <br />Environmental Health Permit/Services <br />395 N San Joaquin, P 0 Box 2009, Stkn. CA 95201 <br />r <br />ew int r.. r s{ <br />eH ta•7a <br />EEE <br />INFOE <br />13-24 <br />AMOUNT Ot1 <br />AMOUNT REMITTEDCX <br />cAsw <br />'RECEIVED BY <br />bATE <br />PERMIT NO, <br />_ <br />