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APPLICATION <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 /> i <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> Application Is hereby made'.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin.'County Public Health Services. <br /> 0 <br /> • Joh Address t� 'Y 76 7' 1. P9 'r 0 f a r, V 1 d, City Lot Size/Acreage �4 U <br /> �. <br /> Owner's Name 01,610Le VV �as l � Address /9 <br /> � +<+b �0 IV 0 �_�^c�e_ �cr Phone <br /> Contractor ry-1 On "+t [!t o C Address /0` V 17°Y ?// rcl *-T,,f,wC License No.�$70J*A Phone Pq a'1651 <br /> TYPE OF WELL/PUMP. NEW WELL O WELL PLACEMENT n DESTRUCTION ❑ Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SY EM REPAIR I lt OTH_ER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK + p r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom L7 Manteca ° 'Na. o7Casi <br /> Excavation Dia. of Well Casing <br /> C.1. Domestic/Private ~ 1 1 Gravel Pack ❑ Tracy Type g_ Specifications <br /> I'I Public Cl Other f1 Delta 7Dep u Seal Type of Grout <br /> II Irrigation _ Approx. Depth I I Eastern S acIn alled by <br /> Repair Work Done LJ Type of Pump H,P. _ State Work Done <br /> ' - "�" Seali Material & <br /> Weil Destruction ❑ Wel! Diameter Dept <br /> Depth 111illff Material Z Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sawer is <br /> � � available within 200 feet.) <br /> Installation will serve:. Residence X Comim cid _ Other <br /> -,_Number of living units: --Z— Number of bedrooms 3 _ f <br /> Character of soil to a'depth of 3 feet: I - I .-- Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg _ tom'" Co +�a t~ 1 tr Capacity 91 No. Compartments l� <br /> € �. \ <br /> PKG. TREATMENT PLT. Cl �r r � � x. � � Method of Disposal <br /> d' Distance to nearest: Well 3 Foundation '14) „ Property Line. <br /> LEACHING LINE No. & Length of lines"- Total length/size <br /> FILTER BED 13 Distance toanearest: Well Foundation ---LD Property Line <br /> SEEPAGE PITS It Depth 1.9.S _Size k3 Number <br /> SUMPS a Qi} Distance to*nearest: f Well '-ISO •_ Foundation Property Line , D <br /> DISPOSAL PONDS ". ❑ <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 /> f rules and-regulations of the Sen Joaquin County { �Y. <br /> Home owner or licensed agent's signature certifies the following: "t certify that iri the performance 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: 'Y certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant m ust call for I r uired spectlone. Complete drawing on reverse side. ! <br /> Signed I + �---" Title —L]Ot,L-?V It 1" 'ar °-713 <br /> _.. Date: — <br /> a <br /> 7 R DEPARTMENT USE ONLY ' <br /> Application Accepted byf Date_ �- Area-al <br /> (9r Grout Inspection by /Datar{.Final Inspection by Dots <br /> .�. <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, GA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED, CASH RECEIVED BY DATE PERMIT'NO. <br /> • EH 14.25 1 V.Fiat Si 6� to ��Lr� J3- <br />