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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES £ <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 'E%PIRES 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 1862 and the Rules and Regulations of San <br /> Joaquin County Publ <br /> ic Healtth�Services. <br /> Job Address ` - C - Cityi6mw Lot Size/Acreage <br /> Owner's Name i LA M40 Address 'Phone <br /> Contracto y Address's � 1915#Lt<Z Yicense N ?lib <br /> TYPE OF WELL/,PUMP: NEW WELL ❑ WELL REPLACEMENTn.` DESTRUCTION ❑ Out of Service Well,!❑ <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑t` t. OTHER Q Monitoring Weli C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL-I PITS/SUMPS _� � <br /> INTENDED U,SE . TYPE OF WELL PROBLEM AREA ° CONSTRUCTION SPECIFICATIONS II t l <br /> 171 Industrial O,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> /1:7 Domestic/Private n Gravel,'Pack ❑ Tracy Type of Casing_ f Specifications JJ <br /> I'l Public ^n Othe'' n Delta Depth of Grout Seal Type of Grout <br /> 11 1 Irrigation Approx.:Depth I I Eastern Surface Seal Installed by <br /> 2 Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter { Sealing Material & Depth t ' <br /> Depth s, Filler Material i Depth �� Er <br /> `s fi <br /> rrt- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION DESTRUCTION l I INo septic system permitted if.public sewer is <br /> available within 200 feet.! i <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> t Character of soil to a depth of 3 feel - Water tab_% depth <br /> leen -I- <br /> ,-'.SEPTIC TANK TypelMfg y capacity4ttnN6. Compartments I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal LLD <br /> g ? Distance to nearest: Well t A �..�. Foundation 1�_ RropertyLine 144n. .., <br /> LEACHING LINFNa..&..LengtFi_of_lines Total length/size <br /> FILTER BED ❑ Distance to nearest:. Well " ? Foundation° Pro arty Line <br /> SEEPAGE PITS i4T--)d, `Depth: Size;. Number t <br /> SUMPS Ll Distance to nearest: # _-y <br /> ,'- Wefl�k � __ Foundation ProperrytLine <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San,foaquin county ordinances, state laws, and <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, I shall not <br /> employ any person in such manner as to become subject tn: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." 1ti " ,f <br /> The applicant must call for all requir if tions. omp a drawing on reverse side. <br /> p . <br /> Signed Title: �- r} <br /> Date:' <br /> t ; <br /> ' µ - FOR DEPARTMENT-USE ONLY ? <br /> Application Accepted by M r. Date <br /> Area <br /> Pitor Grout inspection date Final Inspection <br /> by Date <br /> Additional Comments: ^, r°�l'Nl s <br /> l Applicant - Return all copies:tof San Joaquin County Public Health Services <br /> Environmental Health Permit/services <br /> r 445 N San Joaquin, P Box 2009, Stkn,, CA 95201 <br /> INFO 1If <br /> FFEE AMOUNT DUE �fAM/OUNTJI ITT�ED 1. 'CA �I �ECEIVED BY � TE_ PERMIT NO. <br /> + Eli 1 (REV.11. S1 l „ r 1 r J , <br /> EH 14-M�4s 11 { ( / <br /> � f <br />