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i <br /> APPLICATION RtC19' t. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES199� <br /> ENVIRONMENTAL HEALTH DIVISION `"" <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 O <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 compliance with San Joaquin County Ordinance So. 549 and 1862 and the Rules and Regulations of Sm j <br /> Joaquin County Public Health Services. <br /> Job Address _ �?;�(,�1j?�/�S� �r��� _ City Lot Size/Acreage <br /> 115-v1 zO2- <br /> Owner's Name 40/.96'1 �Address `'I - ,TTh��i9III4 /22E Phone 4f25_ <br /> / / � <br /> Contra[1arGCJ /I/ „i /��C/it/Gtaress 3�6 /i�nUSTI�LicenseNo. �`�/la3`� Phone <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT C 1 OESTRUCTIONejKOut of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS )L�� /IIV4 !�G6 1 L- <br /> Ir7 Industrial ❑ Open Bottom XM anteca Dia- of Well Excavation Dia. of Well Casing - <br /> f.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public I"1 Other n Delta Depth of Grout Seal Type of Grout_ <br /> I i Irrigation ___•Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. 6 late werit Game_ <br /> Well Destruction �[ Won Diameter Sealing Material & Depth <br /> r Depth FillAr Material 4 Depth <br /> TYPE OF SIEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wil Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character-of soil to a death of 3 f IIIZ stat table d"M <br /> SEPTIC TANK. Cl Type/Mfg Capacity, No. Compervitfnta <br /> PKG. TREATMENT PLT.❑ Method of Disposal. . <br /> Distance to nearest: Well oundation Property Lime <br /> LEACHING UNE Cl No. 6 Length of lin at bngthlsize <br /> FILTER BED ❑ Distanca t rant: Weq Foundation rty One <br /> SEEPAGE PITS Depth SiM Number <br /> SUMPS L7 Distance to near t:- We# Foundation Property Line <br /> DISPOSAL"I Q <br /> I hereby certify that I haw prepared this application and that the work will be done in accord4nce with San Joaquin county ordinwww&state LOW.% and <br /> rules and regulations of the San Joaquin Countess <br /> Home owrwr or licensed epa>z's signature certifies the following: "I certify that in the performance of the work for which this pat w-- Is issued, I shah not <br /> employ env person in such m nnw as to become Subject to workman's compensation laws of California.”Contractor's hiring-or sub-eonsirw*p signature <br /> certifies the lokrA4ng: "I certify that in the pedomtance of the work for which this permit is issued,I shall employ persons subject to went rows compansa- <br /> W"lava of California." <br /> i The applicant m4w coq-JIMso rogttired in Complete drawing art revenge side. <br /> Signed X Z., Date: <br /> FOR DEPARTMENT USE ONLY __.._ <br /> Application Accepted by Area <br /> Date $1 <br /> •- <br /> Pit or Grout inspection by Date Final Inspection by Dam <br /> Additional Commem - <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Eavironmental Health Permit/Services <br /> 448 N Sam Joaquin, P O Box 2009, Stkn, CA 98201 <br /> INFOIE AMOUNT DUE AMOUNT REMITTED rCK,,H I RECEIVED BY DATE y� PEfIMtT'NO. <br /> • EFll1tsnlEV.riMel -- - -- I /]� r y� 1 A\ O� - {Y�,f� — <br />