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r _ - <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009; STOCKTON, CA 95201 <br /> PERMIT ESPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for a perrrtit to construct and/or install the work herein described.' This <br /> 1 apPlieation is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 40 <br /> Job Address City Lot Size/Acreage <br /> � 6 <br /> Owner's Name Address Phone <br /> Lic <br /> Contrac Addre� �' '� —_ T <br /> ense N Ph,, <br /> TYPE OF WELL/.PUMP: NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> ry PUMP INSTALLATION 11,-� SYSTEM REPAIR fD--' OTHER ❑ Monitoring Well �] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _FOUNDATION' '•` AGRICQLTURE—WELL"--_ -OTHER WEi L`"`"' PITS/SUMPS- � <br /> INTENDED USE T� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ` ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �1']�estic/Private ❑ Gra--vel Pack? ❑ Tracy Type of Casing_ <br /> Specifications <br /> i'# Public 3 f.1�Other f 1 Delta Depth of Grout Sealr <br /> Type of Grout <br /> ! 1 Irrigation Approx. Depth I I Eastern 1 Surface Seat installed by <br /> Repair Work Done Lel" Type of Pump. H.P. 4�y State Work Done ' <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth'` <br /> Depth Filler Material & Depth <br /> .TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADOITION I 1 .DESTRUC7ION_I I (No septic system permitted if public sewer.is-4� , <br /> available within 200 feet.l <br /> Insillllatian will serve: Residence Commercial Other r <br /> ' '.Number of living units: Number of bedrooms w <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg y a I <br /> PKG. TREATMENT PLT, ElGapacit a t ' <br /> Distance to nearest: Well Foundation ProperM�T 2-94M <br /> F 1 <br /> LEACHING LINE,, , ,E C1;,.,No. & LengiFi of tines ^--�-- T,�. r �A <br /> FILTER BED 7otahlengtSie3 <br /> i3 "pistarice;to `nbarest:' Well :a'Foundation �� R� RS�Pk b-glVl kO <br /> M� <br /> SEEPAGE PITS I'I Depth Sire <br /> .-�.- SUMPS, Number <br /> --_�___ <br /> ..,�,=�,Ll, Number <br /> :�,,_oundation_._-�- <br /> DISPOSAL PONDS C) --Property Line = <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 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 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 permit is issued, I shall em <br /> tion taws of California." ,that in the performance of the work for which this to <br /> P Ploy Persons subject to workman's compensa• <br /> The applicant must call at required insprac' ns. Complete drawing on re� side. <br /> Signed e - � <br /> Title: r Dater <br /> FOR DEPARTMENT USE ONLY .. <br /> Application Accepted by _-1A 42- <br /> Date , Area i <br /> Pit or Grout Inspection by {]ate Final Inspection by z G�� <br /> Data <br /> Additional Commerils- <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 <br /> FEE AAADUNT DUE ��MOUN:� GK <br /> I�NFOA RECEIVED BY DA E ?EgMIT�NO. <br /> . EH 13.21(REV.t M 51 <br /> EH,1.2s { "� <br /> i� <br />