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r <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PA <br /> i OC)`f445 N SAN JOAQUIN, PHONE (209)468-3420 YMIE117- <br /> __.O BO%20U9;:WSTOCgTON—, CA---9 5201— "C'ElVE® <br /> r - --�------- . APR 1 � <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED 1993 <br /> SAN JOAQUIN <br /> (Complete in Triplicate) PUBLICHEALTH COUNITyy <br /> Application is hereby made.to'xSan Joaquin County for a permit to construct and/or instal. h!e iNurN,A1 t3s-7 This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulee and Rego �In <br /> Joaquin County Public Health Services. <br /> lG3 h(df(,� � 4 V City __CI Lot Size/Acreage <br /> Job Address s <br /> Owner's Name ^"" ^ �`-�" Address I/gd pg VAS ��� �Zp vT1 A�hone <br /> Contractor kddressl'�e �BiTls.- K License No.sg/ <br /> CKPhone <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL HI SPLA MENT of �7 DESTRUCTION ❑ Out of Service Well Ll <br /> Monitoring well <br /> PUMP INSTALLATION.❑ _ _ _SYS EPAIR_.i~7 T ER_ �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. OP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial e ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> fa Domestic/Private 1❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other 11 Delta Depth of Grout Seal Type of Grout <br /> I i'Inigation <br /> -- - t�-- AW rox: Oepth- I I Eastern Surface Seal Installed by <br /> Repair Work Done Q Type of Pump 'H.Pr State Work Done _ <br /> # Well Destruction ❑ Well Diameter Sealing Material & Depth D <br /> Depth Filler Material & Depth 6, <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION i 1 REPAIRlADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is (J <br /> available within 200 feet.) vv <br /> Installation will serve: Residence T Commercial_._'_ Other <br /> I Number of living units: Number of bedrooms <br /> i Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal - <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No f;,•Length_af_li_ Total length/size <br /> g_ <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS 's 11 Depth Sire Number <br /> _­_SUMPS, Distance <br /> 2 ,: 1 to nearest: Well-" Foundauori Property Line <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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies-the following:,,.)_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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cfor all. wired inspections. Complete drawing on reverse side. <br /> A - `. t+ <br /> ? Signed - f Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by. -.pate <br /> 2 Area <br /> Pit or Grout Inspection by Date ` Final Inspection by ! ��`//� liGz� DaterL 3 <br /> 'r <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 Sox 2009, Stkn, CA 95201 <br /> k FEE AMOUNT DUE rAMOUNIT REMITTED CK RECEIVED By DATE PERMrT'NO. <br /> INFO CASH <br /> . EM)721[REV.t/"SI `V Dt (� -7 <br /> Er 11•m <br />