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1 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Thi <br /> Application is made <br /> DinrnwithuSancounty <br /> J aquinfor <br /> County Ordinanceconstruct <br /> Ho. 549and/or <br /> 1862Install <br /> and thethe <br /> Rules andhere <br /> Regulationsbed <br /> of Sans <br /> application is madcompliance <br /> Joaquin county Public Health Services. <br /> _ Lot Size/Acreage <br /> City <br /> Job Address f <br /> Phone <br /> Owner's Name ��-g Address i <br /> ,~• "r. � <br /> Contractor Address <br /> -i- icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ t- WELL MEAC�� DESTRUCTION L) out of Service well <br /> 1f OTHER ❑ Monitoring well Gj <br /> PUMP INSTALLATION-O,�k1.. SYSTEM REPAIR.,C7 { <br /> DISTANCE TO NEAREST: SEPTIC TANK ''SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> AGRICULTURE WELL OTHER WELL—... PITS/SUMPS i r <br /> FOUNDATION ; <br /> 'i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 I <br /> piasf Wil Casing <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation r I <br /> s� Specifications <br /> f:l <br /> Domestic/Private ❑ Gravel Pack 4,,,. ❑ Tracy Type of Casing_ <br /> ['I Public CI Other �"I1 Delta Depth of Grout Sealy= ; Type of Grout <br /> i I Irritation Approx. Depth I I Eastern Surface Seal Installed by r <br /> H p State Work Done <br /> Repair Work Done LJ Type of Pump Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter I i <br /> DepthFiller,1Aleterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIAbDITlON ay.[D'ST iTION-i`I`ava(TNoilabPelw Thin 200 fettled r public(sewer is <br /> Ills Installation will serve: Residence.X. Commercial Other r <br /> t <br /> Number of living units: Number of drop a <br /> W.atef table depth �J <br /> so <br /> Character of soil to a.depth of 3 feet: ' ' `. :&, ' <br /> SEPTIC TANK ,�� +❑ Type/Mfg <br /> �L� Capacity d s.,,No. Compartments . <br /> �: Method of Disposal_ <br /> PKG. TREATMENT'PLT.❑tr J } !�. n, ��/""� C — - / } <br /> Mitance tanearest.. Well 'Foundiition'/ PropertyLine <br /> .� Total length/size <br /> LEACHING LINE 0 No. 8 Length 6f`lines /n property Line Orr r <br /> FILTER BED n Distance to nearest: Well Foundation <br /> SEEPAGE PITS 11 Depth r Size_�3J�r Numbers <br /> SUMPS LI Distance to nearest: Well Foundation'- Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with Sant oaquirX .o -may ordinances, state laws, a a <br /> rules and regulations of the San Joaquin County 's '� s <br /> Home owner or licensed agent's signature certifies the followin i_cartity that in the peri ormance_of_the..work for which this permit is issued, l shall nor,; <br /> employ any person in such manner as to become subject to worrkman's co�npensat� ion laws of California." Contractor's hiring or sub contracting signature . <br /> Ia <br /> certifies the following:"I certify that in the performance of the work fo7which this permit.is-issuedrI-shall employ pardons subject to workman's'campensa- <br /> tion laws of California." <br /> The applic for a pection . Complete drawingon reverse side ; <br /> l Date:. ' <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY � ? <br /> 1a a <br /> Date ** Area <br /> Application Accepted,by' a el, <br /> ate - �-s'- Final Inspection by Date <br /> or Grout Inspection by t <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 Box 2009, Stkn, CA 95201 <br /> I ' <br /> FEE AMOUNT DUE° �* , AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO �f <br /> . fH13.24TREV.iin51 11 �i—v" $ `.1��V / ✓-- U — ! <br /> 1 EH 14.70 - I <br />