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V Y....ON-�. .. <br /> APPLICATY " RF�IPER![IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN; PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in Corigtliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic9p. <br /> � Ql)aAl City Lot Size/Acreage <br /> 1 <br /> Job Addresal. ��.�rt���d � 4,1�� <br /> w is Name Address1l f Anal ,, Phone <br /> g 160 <br /> Ada� i-fdAddressCst - License No. Phone A <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR M OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED-USES" —TYPE-OF-WEtL -PROBLEMAREAT--CONST'RUCTION-SPECIFICATIONS �-- <br /> C] I Ems <br /> nal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specilitiation/I'1PI.1 Other fl Delta ;"`—f]epth-of-Grout Seal - Type of Grout <br /> I I Irr align A � <br /> yf _, pprox. 0 h l I Eastern Surface Seal Installed by l <br /> Repair Work Done 0 Type of Pump _ H.Pi� Statb Work Don <br /> Well Destruction © Well Diamet r I Sealing Material l Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION I I (No septic system,pormitted if public rawer is <br /> available within 200"Ieet.1 ` <br /> Installation will serve: Residence_ Commercial_ Other `a <br /> Number of living units: Number of bedrooms r " <br /> Character of soil to a depth of 3 feet: -- Water table depth--- �\ <br /> SEPTIC TANK.- ❑ Type/Mfg -• ;Capacity No. Com6*?fn*nts4 } <br /> PKG. TREATMENT PtT/❑ .- 7 Method of Disposal <br /> Distance to nearest: Well Foundation Propenj Line C <br /> LEACHING LINE CI No. A Length of linea Total Iengthlsize <br /> FILTER BED 11 Distance to nearest: Well Foundation Property Line - <br /> SEEPAGE PITS I I Depth Sire Numbers ' <br /> SUMPS Ll Distance to nearest: Well Foundationf Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; ^'I certify that 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 workman'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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." . <br /> The appy :t call f r all rirgd inspections. Complete.drewing on r rae side. <br /> Sig equTitle: <br /> Date: ;f .q <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by __a �d..e� �9. ��avx� ,n., __.. Date Ares <br /> Pit or Grout Inspection by Date'-- Final Inspection by Date 9 Z� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin 'County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Jdaquin, P O Hoa 2009, Stkn, CA 95201FEE <br /> Val` <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH CV RECEIVED BY DATE PERMIT'NO. <br /> . EH 13.74(REV.1/0%5)PAO <br />