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APPLICATION <br /> SAN J COUNTY PUBLIC HEALTH SERVICES <br /> �� ENVIRONMENTAL HEALTH DIVISION <br /> 445��N SAN JOAQUIN, PHONE (209)468-3420 <br /> IP 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is herebymade to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith' San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of flan <br /> Joaquin County Public Health Services'i <br /> r '' r Lot Size/Acreage <br /> Jab Address,� City <br /> �M <br /> Jr <br /> Owner's Name ddress! Phone <br /> 34 1s <br /> !Address License N���Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT C7 <br /> PUMP DESTRUCTION ❑ Out of Service Well ❑ <br /> f' SYSTEM REPAIR Ll OTHER ❑ Monitoring Well <br /> INSTALLATION ❑ <br /> DISTANCE TO-NEAR ESt:_SERTICTANK = SEW.ER..LINE5.- 2i- D[SP_O.SAI_•FLD" -- -- .PR 'P L - - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> 1 <br /> 'i INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C'1 Industrial ❑{Open Bottom C] Manteca Ria. of Well Excavation Dia. of Well Casing �kp <br /> li*Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_: Specifications <br /> FI Public If i.Other I-1 Delta Depth of Grout Sea! Type of Grout <br /> I I Irrigation Approx. Dept 11 Eastern Surface Seal Installed by ,( <br /> Repair Work Done 0' Tyipe of Pump H.P. � State Work Done _ <br /> Well Destruction ❑ Well Diameter �M Sealing Material & Depth <br /> Depth �M . Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feel.I J <br /> 1 Installation will serve: Rel�idence_ Commercial_ Other x <br /> 1 Number of living units: 11 Number of bedrooms <br /> Character of soil to a depth of 3 feet: WPANAM n <br /> SEPTIC TANK. ❑ 'Type/Mfg �M Capacity M �i <br /> PKG. TREATMENT PLT.❑ V <br /> I �1 <br /> Distance to newest: Well foundation Propert 6 <br /> it <br /> LEACHING LINE ❑ No. & Length o lines Total leng�O#N <br /> FILTER 8ED ❑' Distance to newest: Well Foundation j IZf�1 94fI� Gl WFALTH'Q4VISiON <br /> i <br /> _ SEEPAGE PITS I I Depth �N Size Number - ----R - <br /> `DSUMPS <br /> DISPOSAL PONDS ❑! Distance to n I`re'st: 1Ne11 ' �Foun`dat3n' -�-"Praperty`L-ine�""�` <br /> il <br /> I hereby certify that I have piepared this appli.1cation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> !!! rotas and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "l_ceRffy.thaT in the performance of the work far which.this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmen'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." II <br /> The appfica ust call for 4.All 11required inspections. Complete drawing on r arse side. <br /> Signed X Ile: Date: 7--Z <br /> RTMENT USE ONLY <br /> Application Accepted by I' Date 31— "2- Area <br /> I. I Date 12 "C(2. <br /> Pit or Grout Inspection by Date Final Inspection by <br /> j I <br /> Additional Comments. <br /> ;� ;k <br /> Applicant - Returrrn all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE I� AMOUNT REMITTED �SH RECEIVED BY DATE PERMIT NO. <br /> ♦ IEH 13-24:H t`.�IAEV.i/N5) ! +! [ LJ �v 2�4 - (3-4 <br />