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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 /> k <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby Stade 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address 10"I <br /> ���7 l'�nJ ! 1�ilL�_ City nJ Lot Size/Acreage _Q7Z_*5b•./.9 <br /> Owner's Name "I'll_. pC/[rq Address. Gc�DOJj 7(� � <br /> Phone <br /> f mss. s ,� � �7 <br /> Contractor Address License ryo. <br /> TYPE OF WELL/PUMP: Phone <br /> - NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION Q,Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ on or ng e <br /> { DISTANCE TO NEAREST: SEPTIC TANK U <br /> d SEWER LINES DISPOSAL FLIT. PROP. LINE <br /> = FOUNDATION --A ELL OTHER=WE,LL _ :.PITS/SUMP-S_ <br />! i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y <br /> n Industrial O Open Bottom ffManteca Dia. of Weft Excavation <br /> 1:1 Domestic/Private 0 Gravel Pack ❑ Trac T Dia. of Wall Casing <br /> Tracy Type of Casing_ Specifications <br /> f'I Public El Other Fl Delta Depth of Grout Seal <br /> I i Irrigation q Type of Grout <br /> Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. _ State Work pone_ <br /> Well Destruction 0 Well Diameter � Sealing Mal & Depth <br /> Depth Filler Material & Depth !; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I <br /> REPAIR lADDITfQN I i DESTRUCTION i I {No septic system permitted if public sewer is <br /> Y <br /> Installation will se available within 200 feet.!esidence� Commercial_ Other <br /> Number of living units: mber of bedrooms Z i <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. D Type/Mf <br /> Water table depth <br /> g Capaci . <br /> PKG. TREATMENT PLT.,❑ No. Compartments A <br /> Method of Disposal 1rf <br /> Distance to nearest: Well ation Property Line <br /> 1 <br /> } LEACHING LINE C1 �No. & Len tines t r <br /> FILTER BED Tot th/size !f1 <br /> n nce to nearest: Well Foundation Prope <br /> r <br /> SEEPAGE PITS 11 Depth Sire <br />-•-* •y5UMPS »,m, t „ _ _ Number <br /> Ll -Distance to nearest: -- ?Well------- -Foundations - <br /> DISPOSAL PONDS Q ----- Prope►tY'Line— #+"r - -*..� <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations of the San Joaquin County state laws, and d <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, 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, I shall employ persons subject to workman's compensa� <br /> tion laws of California." <br /> The applicant ml for all req iced inspec ' Is. Complete Wing on reverse side. <br /> Signed <br /> i <br /> ills: eDate " <br /> s <br /> F R DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by Date <br /> Area =�-` ✓I <br /> Pit or Grout Inspection by Date <br /> -- _ Final Inspection by <br /> -.- - tt. Data AA*3 <br /> Additional Comments; <br /> APA i an turtt all opies to o trin unty ubli e i h e "vine' s'laLCi'" <br /> r n to 1 er i,�t"{i,S vi a <br /> 9a an Joaqu n, ® Lioxli'.OS,I' n.. GA 9520] �A t!{� OWL-CS <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED By DATE PERMIT'NO. 4 <br /> . ER 11.21 IttEV.tin s, <br /> 1 00 <br /> tr+,4.ze ,3--/!S7 <br />