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APPLICATION QV10%r ~� <br /> SAN JOAQUIN -COUNTY PUBLIC HEALTH SERVICES- �' " <br /> ENVIRONMENTAL" HEALTH DIVISION JUM g9 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1 P 0 BOX 2009, STOCKTON, CA 95201I�VfR(J1fU`II,?4r.R1� HEALTH <br /> PER NA a ll 501V <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 compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> 1 <br /> .2 �SC6 �) hot Size/Acreage <br /> 10, <br /> Job Address <br /> Owner's Name Address Phone <br /> / o.jVJ.2,�-Phone r <br /> Contractor cess i <br /> TYPE Of WELL/PUMP: i� NEW WELL r45, WELL REPLACEMENT 17DESTRUCTION ❑ Out of service Well El <br /> PUMP INSTALLATION Q SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C3 <br /> " DISPOSAL FLD�PROP• LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK !QOM SEWER LINES r <br /> r - "FOUNDA-TION--_ �'"AGRICUt:TURE WECL---� OTHER-WELL-� 'PITS/SUMPS' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of'Well Excavation' Dia. of Well Casing <br /> i Type of Casin Specifications <br /> Cf�.DomesticlPrivate �Griavei Pack C7 Tracy YP 9 <br /> FI 1 Public Cl Olhe _ n Delta Depth of Grout Seal /-' / Type of Grout <br /> r I irrigation epth �4-Eastern Surface Seal Installed by <br /> Repair Work Done 0 TyWcf Pump N.P. State Work Done <br /> Well Destruction D Well 1'Diameter _Sealing Material & Depth s <br /> ~°` Filler'Miiterial & Depth <br /> h <br /> Deptk <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADOITtON I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial ^, Other. <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth 1 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments '� f <br /> PKG. TREATMENT PLT. ❑ 11 __ ._1 Method of Disposal �l a <br /> Distance to nearest: Well foundation Property Line ; <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS 11 Depth Size Number t <br /> SUMPS LI Distance to nearest: , Well Foundation Property Line <br /> F DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statekaws, an <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, f 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, I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The app' n ca for all a wired inspections. Complete drawing on r rse side.AT <br /> Signed _ Title: te: <br /> FO EPART T USE ON V <br /> +o° ms's— a+?/ <br /> Application Accepted by Date p Area <br /> Pit or four nspection by Date al inspection by Date <br /> Additional Comments: <br /> ii <br /> Applicant - Return all copies to: an Joaquin County Public Health Services <br /> Environmental Health Permit/Services ; <br /> i 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 l <br /> ! t <br /> F A11O'1NT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> . £H 13-24 111FV. <br /> EH 14.26 fl 'I <br /> k- 0 <br />