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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 0 BOX 2009, STOCKTON, CA 95201 <br /> a <br /> if PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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. 549 and 2862 and the ]Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Vis,�,v ` <br /> Job Address rC� "7r C /t`lL.J� i� City Lot Size/Acreage _ 1 <br /> -...� -.Owner's Name..L____'AVtJ2 Mi. _ ...Address . z -ff�-Wi 4141.A9'_LAE!--- P.hone,S2;�Zs*Z <br /> Contractor f Addrestia�,_ Y• �Yi��—� License NQ'2s��� Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service;tfell .❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK ry SEWER LINES DISPOSAL'FLD. PROP. LINE <br /> FOUNDATION # AGRICULTURE WELL ' OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_7 Industrial ❑ Open Bottom J❑ Manteca Dia. of Well Excavation Dia. of Well Casing -� <br /> I Domestic/Private ❑ Gravel Pack "El Tracy Type of Casing_ �= Specifications <br /> Ul Public 1-3 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal)ristalled by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Wel! Diameter ' Sealing Material & Depth. <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I—REPAIR/ADDITION "DESTRUCTION I l INo septic system permitted if public sewer is 7� <br /> r .� , ..available within 200 leet.1 4 I l <br /> .a. <br /> Installation will serve: Residence� Commercial____ 0[hfer <br /> Number of living units: _,L....._ Number of bedrooms <br /> Character of soil to a depth of 3 feet: LzPAM{ `f -- = ' _Water table depth 19, <br /> SEPTIC TANK.aJ!S_r_0 Type/Mfg 'v`fr Capacity.`t No. Compartments <br /> PKG, TREATMENT PLT. I=l `_ .a:.,. `. t Method of Disposal <br /> Distance to nearest: Well Foundation "4°5 Property L'ine_�%,• <br /> LEACHING LINE A No. & Length of lines 40NE {-� ' Total length/size ' <br /> FILTER BED [_] Distance to nearest: Well_ Foundation 2-S "Property Line �7—r{ <br /> E <br /> .'`SEEPAGE PITS Depth, o�� -Size. S62 Number /2 E <br /> SUMPS £4 Ll Distance to nearest: f Well/2 Foundation 7=0 ;'Property Line_Z= � - <br /> DISPOSAL PONDS,," Cl � <br /> I hereby certify that Vhave prepared this application+and that:ihe work-will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County t <br /> {Home owner or licensed.agant'a.signature certifies ihe,follawing;;(_certify thal,in_the_performance of the work for:vihlch this permit is issued, ! shall not <br /> employ any,fierson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ly ; 'certifies the following: "I certify that in the perto mince'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 all required ins c11 S. Complete rawing on reverse side. <br /> i Signed X Title: <br /> FORD ARTMENT USE"ONUY ---��­ <br /> f Application Accepted by _ Date Area y . I <br />` Pit or Grout Inspection by�''J ,I Date ' Final Inspection by Dass <br /> 9 �3 <br /> Additional Comments: <br /> Applicant - Return -all copies to: San Joaquin County Public Health Services <br /> i• Environmental Health Permit/Services <br /> ,,. 445 N,San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHItCEIVED BY DATE PERMIT NO. <br /> . EM13-241REV.+/psi <br /> i EH 14.211 <br />