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APPLICATION <br /> SAjN i7 AQUINCOUNTY PUBLIC HEALTH�VICES <br /> ff <br /> ENVIRONMENTAL HEALTH DIVISION r � <br /> r 445 N SAN JOAQUIN, PHONE (209)468.-3420 ; <br /> P O BOX 2009, STOCKTON, ,dA 95201 <br /> PERMIT E%PIRES .1• YEAR FROG DATE ISSIIED LIAR 1 1 1997 <br /> {Complete in Triplicate) I Vl{ZONMENTALHEALTH <br /> Application' is hereby made to San Joaquin County fora r ��S � <br /> t tifidh = c and/or install the wo This <br /> applicntion_iemade Sn�ompliance�rith San J ouniy Ordinance No. 54+4and 1862 and the Rules and Regulations of San <br /> Joaquin C6uiity'Pdbl1d Hisalth Services.. gu <br /> Job Address -5{ C ;,b7 ,vG_ y.11 xit_� (� City_( j (�� Lot Size/Acreage ] f� <br /> Owner's Name ` �.j AAA= GSC-r�Y��i 23-r� <br /> Address Phone " <br /> Contractor ►tJ. __ <br /> f1d� 3.1ll AddressA00r. License No.C, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ L REPL C MENY _r1j� DESTRUCTION Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION —JdlAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial p Open Bottom ❑ Manteca Dia, of Well Excavation �r Dia:of Well Casing M <br /> N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ +t JG Specifications <br /> 11 Public Other pA&4jfVRv4LS1 Delta Depth of Grout Seal -v—Z-] _ Type of Grout re <br /> I I Irrigation ctI Apprax. Depth I I Eastern Surface Seal installed lay <br /> Repair Work Done L] Type of Pump fij I H,P. _ `� `State Work Done <br /> Well Destruction Cl Weil Diameter Sealing Material 6 Depth f3 <br /> Depth Filler Material i Depth €� <br /> TYPE OF SE IC WORK: NEW INSTALLATION.I 1. REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ll�"!11 //f+ available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ 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 O Type/Mfg Capacity No. Compartments <br /> .PKG. TREATMENT PLT: ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Toial length/size <br /> FILTER BED g#1]/1 ❑ Distance to nearest. Well Foundation + Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ��££Yy11 Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PO JP ❑ i <br /> I hereby certify that t 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 /> 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 4 <br /> employ any parson in such manner-as-to become sube oft workman s ctsmpansation_Iaws�#California."Contractor's hiring or sub-contracting signature <br /> _ �.T _ <br /> certifies the following: •'I certify that in the performs i the work for which this peimit is iasued;'�l-shall employ-parsanrsubject to woikman•s compensa- <br /> tion laws of California." <br /> The applicant must call for ail re Complete drawing on reverse side. <br /> Signed 9 Title: Vv�,-23me:7- Date: --4[9"-T7 <br /> FOR DEPARTMENT USE ONLY ,iii <br /> Application Accepted by Data 3 ! Area <br /> Pit or Grout Inspection by Date /,�, 'Final Inspection by Date <br /> Additional Comments: -- l' � O�—w"� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental health Permit/Services ` <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE ) <br /> - I <br /> INFO AMOUNT DUE MOUNT REMITTED CK 11 <br /> ASH RECEIVED BY DATE PERMIT'NO. <br /> • EH/7.24 IREV.r i n 51 � X77.+ A i-,age i 3 <br />