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it J <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> PERMIT EgPIRES I YEAR `FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County fora "* f <br /> permit to construct and/or install the work Ijerein"described. This I <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules atld Regulations of San f <br /> Joaquin County Public Health Services. i, <br /> Job Address 4 City Lot Size/Acreage — <br /> Owner's Name Address Phone <br /> Phone — 7 <br /> J // �? ��// 9rf.�'7/ '.' SPI/-3o-ice <br /> Contractor/ / i�4@Sress AQ " 336 kor 5TH t�3/ 3 '` <br /> f License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT 171 DESTAUCTION, Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ y Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I'PROP. LINE <br /> FOUNDATION :AGRICULTURE WELL OTHER WELL 1PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /LJq,(/jTVit' " CL6 1,4,1- (/ <br /> Cl Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of;Well Casing <br /> (.1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing- Specifications <br /> Il Public (-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ! 1 Irrigation _Approx. Depth I I Eastern Surface Seal installed by t <br /> Repair Work Done 0 Type of Pump H,P. _ <br /> Well Destruction `,� Well Diameter Sealing Material i Depth <br /> I Depth Filler Material i Depth <br /> TYPE OF EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I ! INa septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation wil e: Residence— Commercial Other j� <br /> Number of living units: Numb�ofbeclrooma <br /> J. <br /> r <br /> Charmarof&oil 10 a depth of 3 fee. atsr table depth' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal.- k <br /> " <br /> Distance to nearest: Well oundation' Property rt Line <br /> LEACHING LINE Ll No. & Length of line al length/size 11 <br /> FILTER BED ❑ Distance to rest: Well Foundation 7"oLine i{ <br /> f <br /> SEEPAGE PITS Depth Size .Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line II <br /> DISPOSAL ONDS © ti ` <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state iews, and <br /> rules and regulations of the Son Joaquin County i� " <br /> Horne 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." E <br /> i <br /> The applicant m at call Pr all reqi4tired ins , tions. Complete drawing on reverse side. <br /> Signed Title: _ Date: &W-191:5 <br /> (�c�c FOR DEPARTMENT USE ONLY r F <br /> Application Accepted by Date V 3 Area- <br /> Pit <br /> ron - <br /> Pit or Grout Inspection by Date Final Inspection by <br /> r <br /> Additional Comments: — Ili _-I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box_2009, Stkn, CA 95201 i <br /> INFO <br /> FEE AMOUNT <br /> DUE AMOUNT REMITTED C K J RECEIVED BY DATE j� IPERMII'NO. <br /> . EM 1}Zi tAEV.rir sf — 7 �ff- 1�3 <br />