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`'APPLICATION. <br /> i, <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 /> I (Complete in Triplicate) <br /> Application is hereby made,to SJ-Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance t.with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public/HealthServices. <br /> 2�1Job Address ��+ �• D� v City Lot Size/Acreage <br /> Owner's Name e 1 Address of Phone <br /> Contractor <br /> O Address ! d' icense No Phone a{ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE 7Q NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il PUblic C7 Other ;- t-1 Delta Depth of Grout Seal Type of Grout <br /> I I Iffi ation '_,.Approx. De h ,�I_I Eastern 5 Seal Installed by <br /> e . a <br /> Repair Work Done Type of Pump H•,P - Stile Work ` <br /> Well Destruction ❑ Weil Diameter Sealing tenial 8 Depth <br /> Tt <br /> Depth Filler Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONS I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ '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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 . -W Method of Disposal (� <br /> Distance to rietirest: Well ` Foundation Property�Line I <br /> LEACHING LINE 0 No. & LengtY%iif lines''T ` wf. Total lengthtsize -s <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line �II <br /> SEEPAGE PITS 11 Depth Size Number f J <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 -- <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 i <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu all f all required ins p , ns. Complete drawing on to se side. <br /> Date: � ... <br /> i ned Title: <br /> sg <br /> �FO DEPARTMENT USE ONLY ^� p <br /> Application Accepted by _�l 4 -- Date ��`Z• l Z rea <br /> Pit or Grout Inspection by �bt ''. Date ° Final Inspection b ' Date. - <br /> Additional Comments: _ - <br /> Applicant - Return all copies to: -San.-Joaquin 'Counti VUblic_ Flealth Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMII'NO. <br /> INFO <br /> . EH1321[REV.k i x 51 r] <br /> EH 14.28 <br />