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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3 ! Po­3�3-lo <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete in Triplicate) <br />{ Application.is hereby made to San Joaquin County far 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 Public Health Services. <br /> Lot Size/Acreage � S— <br /> Job Address ] rrr..ryf��ff( City C+ <br /> rAddress Phone <br /> Owner's Name � t � <br /> + ' Q <br /> Contractor <br /> Address License ryo <br /> 'phone <br /> ox bervice Well <br /> TYPE OF WELLIPUMP: NEW WELL ❑ �RLIINES'y <br /> ELL REPS AGEMENT 171 <br /> DESTRUCTION ❑ a't monitoring Well <br /> PUMP INSTALLATION ❑ SSTEM REPAIR L7 OTHER ❑ t <br /> ' I DISPOSAL FLD. t PROP. LINE, _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINi <br /> FOUNDATIONAGFiI U URE WELL OTHER WELL �PITSIS•Ut1APS "` s <br /> INTENDED USE TYk OF WELLk_A�RROBLW AREA', CONSTRUCTION SPECIFICATIONS <br /> ❑ 0' n Bottom ❑Manteca` Dia..of Well'Excavation —=i.� Dia;-of Wel Casing <br /> E 1 Industrial Pe l i f t Specifications. <br /> 1 f7 Domestic/Private ❑ Gavel Pack M,Trac Type of Casing_ <br /> I'i Public CI Other - 4 Cl Q It "`� Depth`of Gr6ui Seal Type of Graut'r <br /> i : <br /> I I Irrigation �.Approk. Depth 4 I Eastern Surface Seal tnstalled by r(� <br /> I t ! H:P. t-1 State Work-Dona — — (9 <br /> Repair Work Done U Type Pump t <br /> Sealing Material de,l)epth V- <br /> Well Destruction ❑ Welliamiter <br /> f Fillet Material 4FDepth + <br /> i.Depth? ,�-• <br /> TYPE OF SEPTIC WORK:)NEW INSTALLATION I l REPAIR/ADDITIONDE5 TRUCTION 1 I.[ &septic.system permitted if public sewer is <br /> 5 avgablo wit hiri-200 feet.l <br /> Installation will serve: s Risidece_�C115mmarcle—, Other <br /> Number of living units. Number of be rooms__ 151_ r M,•, <br /> Water tabla,depth <br /> Character of sail to a depth ofi 3 feet: ,� i , <br /> SEPTIC TANK iO Type/Mig ! �- �a —ICapacity � NQ• Chntents <br /> r <br /> PKG. TREATMENT PIT. Li Method of Dr�isposal <br /> Distance,to neereSt� 1Neq .F.oundatio�.. ' P199,Brty',P��� <br /> LEACHING LINE ❑ No. &4Length_of lines a � � t� --- Total len <br /> 0. fn <br /> FILTER BED n- Distance to nearest: Well =- Foundation Prot'pe ine 41' <br /> SEEPAGE PITS 11 Depth Size Number ' <br /> 1 r <br /> SUMPS i l Distance to nearest: Well � i Foundation .1 Property Line <br /> DISPOSAL PONDS ❑ f <br /> �: <br /> I hereby certify that I have prepared this application and that I#ie�work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San�ioaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that <br /> 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 workmer'.s compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify tat 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 must c I for all required in".cti ns. Complete d Ing on reverse side <br /> Signed X Ti moi- IL-6-L, Date <br /> : <br /> i s,wt <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by Date ^� 2" Area J) <br /> Pit or Grout Inspect n by Date Final Inspection by Data1 Y <br /> Additional Comments:, �''} ' e a LU ' <br /> Applicant - R turn 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 /> FEE "AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO- <br /> i INFO <br /> rt' �e. (j 755 <br /> . EH 13-24IREV.1�w51 � f`; •�� 3 1 �Q [/ -FS <br /> EH 14-IE <br />