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r A� <br /> APPLICATION <br /> U R <br /> SAN jOAQ IN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ' 19 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445�� N SAN JOAQUIN, PHONE (209)468-3420 MAY 6 92 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ENV IRON M E-_NTAL H'E_AL'1,*H <br /> it PERMIT/SERVICES <br /> 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 comjllance vith,San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.alI <br /> Job Address —Lot Size/Acreage <br /> Owner's Name =z7 Address Phone <br /> Contrac Address&&&J?6_A�152A_yLicense ;?---Phont�-2arn� <br /> TYPE OF WELL/PUMP: oil: NEW WELL 0 WELL REPLACEMENT n' DESTRUCTION Ei out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 9)-_' OTHER 0 Monitoring Well <br /> ❑ <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES DISPOSAL FLD.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> P_150mastic/Private Cl Gravel Pack 7 0 Tracy Type of Casing Specifications <br /> i'l Public I'l 'Other Ir C1 Delia Depth of Grout Seal Type of Grout <br /> I I-l'irfigationApproK. Depthi__t I.Eastern' Surface Sedi Installed by tN <br /> T Sii <br /> Repair Work Done Type of Pump -41�� H.P. is-Work Done <br /> Well Destruction 0 W;il Diameter Sealing Material' & Depth T <br /> Depth Filler Mater'lal-C.Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR 1ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> 'i� ­ . available within 200 teat.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character Of soil 10 a depth'of 3 feet; Water table depth <br /> SEPTIC TANK. 13 ,Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 <br /> Method of Disposal <br /> Distance to nearest: Well -Foundation— Property Line <br /> LEACHING LINE 0 :No. & Length of!dines Total length/size <br /> FILTER BED 0 1:6istance to nearest'. Well Foundation Property Line <br /> SEEPAGE PITS 11 rDepth Size Number <br /> SUMPS Ll Distance to nearest, Well Foundation— Property Lino <br /> DISPOSAL PONDS 0 $ 11 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 <br /> rules and regulations of the S9n Joaquin County <br /> Home owner or licensed agent's signature conifies 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 rna!Anar 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 per(o7rmance 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 ijist-ea ing <br /> rr Qhr allirequire# in6pe.chons. Complete draw' ide. <br /> ySigned X Title: Date: -/.3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> L <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 0 Box 2009, Stkn, CA 95201 <br /> EC RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED. CK <br /> CASH• <br /> EN 3-24(AEv.1J"5)1P9 0137 4� <br /> EH 114-26 7 15 <br />