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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN TOAQUIN, PHONE <br /> (2CA)95201420 <br /> P O BOX 2009, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} <br /> e to gas Josquin County for a permit to construct and/or and instal62 and tthehe Awork he <br /> ules andeRegulationain dof Sans <br /> Application is hereby compliance with San Joaquin County Ordinance No. 5 9 <br /> application is made in comp .7ps ? <br /> Joaquin=.Cotutty Public Health Services. ,",,�� ` % Lot Size/Acreage — <br /> City F�uS[--- <br /> Job Address X '�- <br /> Phone <br /> ` Address <br /> Owner's Name �, t; d QS63 y _ <br /> cense-fyo:r�G Y�.a --�Phone� <br /> Contractor tL�1�1L Hddress DESTRUCTION ❑ Out of Service Well ❑ <br /> N WELL ❑ WELL REPLACEMENT Ll OTHER ❑ Monitoring Well D <br /> TYPE OF WELLIPUMP: SYSTEM REPAIf� <br /> PUMP INSTALLATION ❑ / <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL SEWER LINES -- — OTHER WELL— <br /> PITS/SUMPS <br /> FOUNDATION —�---- ' <br /> PROBLEM ECIFICATIONS w <br /> INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPpia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia: of Well Excavation <br /> L-} Industrial Specifications <br /> ❑ Tracy' Type of Casing_ <br /> Domestic!Private 0 Gravel Pack Type of'Grout <br /> !-1 Other f1 Delta Depth of Grout Seal + <br /> I'1 Public Surface Seal Installed by <br /> + I I Irrigation Approx. Depth I I Eastern State Work Done <br /> of Pump H.P. �—�----- <br /> Repair Work Done 0 Type Selling Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br /> available within 200 feet.l <br /> TYPE INSTALLATION I i REPAIRhAODITif)N 1 I DESTRUCTION I i 1No sept <br /> QF SEPTICWORK; NEW ic system permitted if public sewer is <br /> Yr <br /> Commercial ,Gtiier <br /> installation will serve: Residence \�\ <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity ---SEPTIC No. Compartments; <br /> ` SEPTIC TANK D Type/Mig Method of Disposal <br /> PKG. TREATMENT PLT.❑ property Line <br /> Distance to nearest; Well Foundation f r� <br /> - Total lengthlsize <br /> LEACHING LINE C] Na. 8 Length of lines <br /> ❑ Distance to nearest: Well ''Foundation ���'~ Property Line <br /> ` FILTER BED <br /> r <br /> $1zg Number I <br /> SEEPAGE PITS Ii Depth r pro Line ��— <br /> k Foundation paw' <br /> SUMPS LI Distance to nearest: We111---- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and tha4 the work will be done i�ardance with SoJoaquin county ordinances, state laws, an <br /> d, I shall not <br /> rules ar, k <br /> nd regulations of the San Joaquin County following: <br /> Horne owner or licensed epent's signature certifies bet to workman's compensation II'll certify that in the paewsool-Californian"Contractowork for r's orhis sub contracrmit is ting signaturepen <br /> employ any person in such manner as to become subject <br /> certifies the fallowing: "1 certify that in the performance of the ork for which this permit is issued, shall employ persons subject to workman s compen <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse sr e. v <br /> Date: <br /> r <br /> -' Title: <br /> Signed ; �:� <br /> -DEPARTMENT-USE'-ONLY <br /> f_ t f1 <br /> I' Date fiw Area <br /> Application Accepted by Data — <br /> Q <br /> Final Inspection by r <br /> t Pit or Grout Inspection by Date�l yr <br /> Additional Comments <br /> Applicant - Return all copies to: Environmentalan Joaquin oHealth unty upermit%Servicess blic s <br /> k 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT D E AMOUNT REMITTEE <br /> CK ECEI D BY ATE ?ERMIT'NO. <br /> INFO � � � •- <br /> r r <br /> ' . EH 13-24 111+ -- <br /> EH 14.75 <br />