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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)49$-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT R IRES 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 vork herein described. This <br /> application Is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> City' <br /> it Lot Size/Acreage <br /> r4 <br /> ` Owner's"Name Com` - ` _ Address <br /> Contractor r Addresi- se <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n— DESTRUCTION Cl Out of Service deli ❑ <br /> f PUMP IlrlSTALLATlON,❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well � <br /> DISTANCE TO NEAREST: SEPTIC TANK �' SEWER LINES t DISPOSAL FLO. PROP. LINE <br /> FOUNDATIONS r." AGRICULTURE WE , OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ❑ Manteca' Die:,of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private El Gravel Pack I Die:; <br /> of <br /> Type of Casing_.- Specifications <br /> 1'1 Publf�ic El Other r belt I q � Depttf�of Grout Seal Type of Grout <br /> I I Irrigation —..Approx. Depth I I Eastern Surface Seal Installed by O <br /> Repair Work Done U Type of Pump H.P. �r <br /> State Work Done <br /> Well Destruction O Well Diameter dealing Material & Depth <br /> Depth 4 Filler Material & Depths- <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No seplic system permined if public sewer is <br /> ¢ available within 200 feet.) <br /> Installation will serve: Residence ap._ Commercial_ Other /sem /J a <br /> ._Number of living units: -L—: Number of bedrooms � ��s�F ^! (1A <br /> 0 Character of soil to a depth of 3 feet: - "� ; r Wifi r table depih <br /> i—SlikT-IC TANK- N&1W T e/Mf :� ✓— �� .• # <br /> Si°� Type/Mfg 9 — —.. Capacity No. Compartments <br /> ry <br /> PKG.a TREATMENT PLT. 0 -' ; ` '`� <br /> : ,I <br /> _ 4111, t Method of Disposal. <br /> Oistapce`to nearest: <br /> We Z_ Foundation . Property Line <br /> T i.•. <br /> LEACHING LINE , No & Length of lines Total length/size ` <br /> FiLTER�BED [3�Distanceto nearest, 'Well,�tFou ndalion --� _ Property Line I�` , <br /> SEEPAGE TOTS'N `.; "I D@p?t `FAQ Size Number <br /> f <br /> SUMPS . F Di �_ <br /> ya," ! L1 stance to nearest: WeII__ Foundation Property Line ` <br /> DISPOSAL PONDS p <br /> I herekiy certify that 1,118xe,prepa'red:this.application and that the work will be done in atcordance with.San.Joagain 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&t . <br /> employ any peradn in such manner as til become subjett to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cettrfieai 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 iaws of Califorria." r <br /> The applica t all for all requi d,i.- pect' nssCb <br /> 4F fnpl drawing on reverse side. <br /> }ip. d <br /> Si d X <br /> _ dater i <br /> FO DEP RTMENT USE ONLY f <br /> Application Accepted by" Date r Area <br /> Pit or Grout lnapectiian by v' -Date Final Inspection b.. pate <br /> Additional Comments: <br /> Applicant'- Return all copies to: San-Joaquin County Public Health Services + <br /> �ttvironmental Health Permit/Services <br /> 445 N San Joaquin, P O Rox 2009, Stkn, CA 95201 <br /> t <br /> FEEkAMOUNT DtJE AMNT REMITTED aCK [ RECEIVED BY DATE PERMIT'N0. <br /> INfO8EH 13-24 IREY.?1 i nEH 14.26 .0". v <br /> y <br />