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APPLICATION 1 <br /> P SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL4HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE {209}468-3420 <br /> P O BOX 2009, STOCSTON;r CA 95201 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> (Complete in Triplicate) 1 <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 No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address Lot Size/Acreage 232,014 <br /> II Owner's Name Address 1 I�Phone �7 <br /> - <br /> -License-No =Phone-% d <br /> 1. .�:Gontrattor� _ . _ Address- r - <br /> TYPE OF WELL/PU NEW WE WELL REPLACEMENT Fl DESTRUCTION ❑ Out of service IWell ❑ <br /> I PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER C1 Monitoring,Nell <br /> U DISTANCE TO NEAREST: SEPTIC TANK �~ SEWER LINES o� DISPOSAL FLO. 1,�_ PROP. LINE a Sats t <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL,,--- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS !l - <br /> l� Industrial Open Bottom 11 Manteca Dia: of Well Excavation Dia. of Well Casingr+ <br /> i Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications <br /> j i Type of Grout <br /> Il Public f:7 Oth�r fl Delta. Depth of Grout Seal � <br /> rngation : Approx. Depth I I Eastern w.. Surface Seal Installed by <br /> Repair Work Done U Type of Pump A H.P. � -. <br /> State Work Done <br /> Well Destruction --S�-Well-Diamete sealing Material th .¢ � <br /> Filler Maters Depth 'r <br /> f i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <br /> jInstallation will serve: Residence_ Commercial— Other-- <br /> Number <br /> ther -Number of living units: Number of bedrooms <br /> jCharacter of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ '.Type/Mfg Z< —." .Capacit_Y �No• Compartments <br /> I r Method of Disposal <br /> i PKG. TREATMENT PLT. ❑ <br /> 'Distance to nearest: - II, Foundation Property Line f <br /> - � - <br /> k LEACHING LINE C1 No. & Length of line Total length/size <br /> FILTER BED Cl !Distance to neares Well Foundation Property Line r <br /> i <br /> I SEEPAGE PITS t 1 j Depth Size - Number t <br /> SUMPS Ll Distance ton rest: Well -,A 'k, ,i Foundation Property Line <br /> a <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the-work will be done in accordance with San Joaquin county ordinances, statelaws, and r { <br /> i rules and regulations of the San Joaquin County t <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far 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 sub-contracting 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 lows of Californl <br /> The applicant mu t i �pletewing on reverse side. ` A <br /> Signed -.. Title: „_� ,_ _ 'Q - Date: <br /> ;l F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area D <br /> Pit or G out spection b <br /> Date Final Inspection by Data <br /> Additional Comments: <br /> r <br /> I. Applicant - Return all copies to: San Joaquin.County Public Health Services <br /> Environmental Health Permit/Services <br /> _ � . w ate--�-•. — .. -� <br /> ,. .�,.�.,,_,...�445-N-San•Joaqui•n-,-P�-O-Box-2009 Sticn; GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED i CASH .RECEIVED By- "a } -DATE PERMIT'No. <br /> INFO <br /> II . EM 13-241REV.sin sl W �Q� Z f .. . <br /> J <br /> II EK 14.26 y+• L. .... ��f <br />