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0 APPLICATION • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTHDIVISION jl ����1� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3QI nl�tl/In� <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IssuEDJAN 1 6 1992 <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or instal {����ed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and theN done of San <br /> Joaquin County Public Health Services. cl <br /> Job Address `Z (a 11da f1 Sk - City Lo , \`Lot Size/Acreage <br /> Owner's Name C.�f.0 S40C_A Address %_VV S llsn S! Phone 3CA 2SY-4815TE) <br /> tlz�s esti>�D <br /> Srmr4.4 f ell trel2 <br /> Contractor Address License No.0 S�2hPnone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL•REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION i SYSTEM REPAIR ❑ OTHER $e ��ttott��S toring Well L]l` Nc1�j <br /> DISTANCE TO NEAREST: SEPTIC TANK 7i� SEWER LINES 7 �SO� DISPOSAL FLD.W 06 PROP. LINE _L'_� <br /> FOUNDATION AGRICULTURE WELLZLXJO� OTHER WELL�?� PITS/SUMPS ►�IL+�. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "" 11141111 Dia. of Well Casing <br /> XDomestic/Private ❑ Gravel Pack L-1TracyType of Casing-_.''A Specifications ,�` <br /> I'I Public Other56Oe � ' Delta Depth of Grout Seal 0*4 Type of Grout$P:�y <br /> I I Irrigation 3Q!Approx. DeptMh+ 1 I Eastern Surface Saul Installed by �(P1 i•.L�N -N+QIN� SCJ <br /> Repair Work Done ❑ Type of Pump H.P. ♦ State Work Done _ \ <br /> Well Destruction ❑ Well Diameter Sealing lfaterial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR"ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l _ <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT. ❑ s Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> e <br /> LEACHING LINE ❑ No. i Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation_ Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 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 subcontracting 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." <br /> The applicant must call for all require insp tions. Complete drawing on averse sips. <br /> /-1' / <br /> Signed % (//' Title: S�n•'.'.ar �(/1�+idqDate: <br /> � <br /> =°)C. <br /> FOR DEPARTMENT USE ONLY - / <br /> Application Accepted by 9 'R/TyqCq Date Area <br /> Pit or Grout Inspection by c��' Date��L?-Finsl Inspection by `` Date <br /> Additional Comments: dJ.J <br /> Applicant - Return all copies to: San oaquin County Public Health Services <br /> Environmental Health Permit/Services �/�/d <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 7 7 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT <br /> NO. <br /> EM UAIREV.vnL ��/ � V v ^ - - / /-�/U <br /> EH 14 20 NFD [[ _!/2_ ///lVV///////lll���r/r✓// <br />