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ar <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE � <br /> P 0 BOX �+ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAS SEP f 1992 <br /> {Complete in Triplicate) F0QLj AQUINC <br /> E"C� o <br /> Application is hereby made.to San Joaquin County rhis <br /> for a permit to construct and/or install the v ons'. FFfbin <br /> Application is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and e rr5 !j'JSiojv <br /> Joaquin County Public Health Services. <br /> City_ Lot Size/Acreage <br /> Job Address <br /> � Address Phone <br /> Owner's Name f <br /> i <br /> F <br /> one <br /> se <br /> se <br /> Address No. <br /> Contractor t of Service Well ❑ <br /> TYPE OF WELL/PUMP: NE WELL 71WELL REPLACEMENT C1 DESTRUCTION Monitoring Well �� J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ' DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ <br /> r- _ � --FOt1NDATiON ' "71GICIJk TURE WELL '-OTiiER WELL �— PITS/SUMPS ___ <br /> I <br /> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> h Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Specifications <br /> J'] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Type of Grout <br /> I'1-Pilblic 1-1 Other n Delta Depth of Grout Seal <br /> II 1 Irrigation _.Approx. Depth 11 Eastern Surface Seal Installad by , <br /> Repair Work Done 0 JEYpe of Pump H,P. Stat o DQr_e D <br /> e/ Sealing Material & Depth � l <br /> Well Destruction Well Diameter Filler Material & Depth <br /> i Depth <br /> JYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I -DESTRUCTION l I� (No-septic system permitted if public sewer is ` <br /> ` available within 200 feet.) <br />!, Installation will serve: Residence— Commercial Other , <br />'i Number of living units: Number of bedrooms + '` I <br /> t I Water table depth <br /> r'Character of soil to a depth of 3 feet: <br /> !SEPTIC TANK.. ❑ Type/Mfg Capacity_ 'No. Compartments <br /> " Method of Disposal`r r <br /> PKG. TREATMENT PLT. ❑ <br /> _Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE F CI No. 8, Length of lines Total length/size <br /> FILTER BED [1 Distance to nearest: Wall Foundation Property Line <br /> r' <br /> f <br /> SEEPAGE PITS t I Depth Size Number ` <br /> SUMPS LI Distance;to nearest:._ . Weil. . Foundation _ _Property.Line,- , — +- <br /> DISPOSAL PONDS ❑ _1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanceY state laws, and <br /> rules end regulations of the San Joaquin County !i" y <br /> Nome owner or licensed agent's signature certifies the following: "I-certify that in the performance of the work for which this permit is issued„1 shall no <br /> employ any parson in such manner as to became subject to workmen's compensation laws of California.” Contractor's hiring or_sub-contracting signature <br /> rfertifies the following: "I certify that in ih performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa— <br /> tion laws or <br /> The spplican ca for al requi spectio s. Complete drawing on e e se sid . <br /> Signed X Title: Date: <br /> q__� <br /> 4UY7 %A FOR DEPARTMENT USE ONLY <br /> Date Area Z <br /> Application Accepted by <br /> F, 2 Z <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> I Z <br /> *dditional Comments: <br /> Applicant - Return all, copies to; San Joaquin County Public Health Services <br /> i Environmental Health ,Permit/Services <br /> I ` 445 N San Joaquin, P O Box <br /> 2009 2009, Stktt, GA 95201 <br /> FEE r i <br /> ( AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY 9ATE <br /> INFO PERMIT NO. <br /> . EH 1 <br /> 3F24{REV'I/A si e r <br /> EH I4-26 ��+ } t <br /> rt <br />