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` APPLICATION I� <br /> . � <br /> SAN JOAQUIN COUNTY PUBLIC HEAip LTHIrSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION COPY\.,445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, rCA 95201 <br /> . II, <br /> PERMIT EXPIRES I YEAR FROM DAT ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construe t,and/orlins tall the work herein described. This .+ <br /> application is made in coupliance vith San Joaquin County Ordinance No. 54§ and 1662 and the Rules and Re tions of San <br /> Joaquin County Public Health Services. .1[ !I� A. r —>D�d—� / r <br /> Job Address 'f • City ZLot Size/AcreageAlf* <br /> Gx <br /> rrrl� fiverc� - 'F <br /> Owner's Name Address Phone <br /> 7 C� <br /> Contractor r A.—Tress 30 � "`ALicell se No. Phone <br /> TYPE OF WELL/PUMP: NEW ELL 0 WELL REPLACEMENT n 11 ,,DDE7ESTRUCTION 0 Out of S*rvice 11e11 Q <br /> PUMP INSTA CATION �• ' ., SYSTE REPAIR �i�/Ja►` THER � Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAMC � SEINER LINES.yDISPOSAL FCO. PROP. LINE <br /> FOUNDATION -AGFi1CULTURE ELL jL ;OTHER ,WELL PITS/SUMPS. /r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA'" CONSTRUCTION Sf?m!ECIFICATIONS <br /> L1 industrial ❑ Open Bottom 0 Manteca Dia. of Weil Excavation l Dia. of Weil Casing <br /> Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ 11 Specifications � <br /> I'I Public El Other Cl Delta Depth of Grout Seal1� �� Type of Grout <br /> I I Irrigation _Approx. Depth l I Eastern Surface Soul Installs Id by 1 I <br /> r Repair Work Done 0 Type of Pump H.P. �I State-Work Done <br /> Well Destruction ❑ yfe4 Diameter .c Sea li te;tal & DepthIr <br /> . th F11Ir!� Material i Depth SII �I <br /> TYPE OF SEPTIC WORK: I TAL TION I i REPAIRIADDM b1 I ,DESTRUCTION I IANo septic system permitted it public sewer is <br /> � ,. available within 200feet.F <br /> Installation will serve: Resi&;Pc ' Conrnercw 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 �I �I No. Compartments <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal a <br /> Distance to nearest. Well Foundation LProperty Line <br /> LEACHING LINE ❑ No. b Length of fines Total Ierigth/size <br /> FILTER BED 0 Distance to newast; Well Foundation :'Property Line <br /> SEEPAGE PITS 11 Depth Size J Number <br /> I <br /> SUMPS L1 Distance to nearest Well Foundation '' <br /> "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 woth San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin Couat:y <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�Californa." Contractor's hiring or sub-contracting signature U <br /> certifies the following:"I certify that in the pertormartca of the work for which this permit is issued. I e4l employ persons subject to workman's compenaat <br /> t tion laws of California." <br /> Thea applicant mus I required squired 'ns - Complete drawing on rev side. 1 ,- <br /> Signed L Title: L��VI Date' r� <br /> FOR DEPARTMENT USE ONLY jl <br /> ' I' g(� <br /> Application Accepted by IF C <br /> iiDateI Area ` r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> �jQ <br /> Additional Comments: 9^-' � �i <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> �Se I ��D I <br /> Environmental Health Permit/Services ' <br /> 445 N San Joaquin, P 0 Box 2009, Stke, IICA 95201 <br /> JJ s <br /> s INFO AMO{UJNQT dtJE 'A1g.10UN(TAEMITTEO SAFEESH RECEIVED BY OA7EQPfRM7�Tj'�NQO. r <br /> . EN 13.24 tfl£V. i <br /> 1<•]D n 5� �•, J[ l `^ (� ! / _ I� Iii / I� / Ft6_3SEiiJJ 6Cl <br /> it <br />