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APPLICATION' <br /> T ' J SERVICES `� Cl <br /> SAN OAQUiN COUNTY 1 ELIC HEALTH 5E /,� <br /> ENVIRONMENTAL I 1EALTH DIVISION `�' ✓ <br /> 445 N SAN JOAQUIN,I BONE(209)469-3420 `C <br /> P O BOX 388,STOCK ON,CA 95201-0388 <br /> EXPIRESl YIAR FROMD IMED 5U.` <br /> (Complete i Triplicate) �� N( � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or in all the work herein described.This application is made in compliance uit��tt <br /> Joaquin County Development Title Section 9.1110.3 and Section 9.1115.3 and the R les and Regulations of San Joaquin County Public Health Services. <br /> Job Address Ct V"A4- 4�C ST City �oC-k74 Got Size/Acreage <br /> Owner's Name Fir Le- Ual-&^ Address _ 3:Z -' Q fV_ i -V AhAi - 5�t Ph e y <br /> Contractor ' Address _ 1�. license Nof= � F� Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL AV LACEMENT n DESTRUCTION O out of Service Well O <br /> .' PUMP INSTALLATIO G SYS EM REPAIR O OTHER O .3 Monitoring Well <br /> K ( <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES � DISPOSAL FLO./"1. �y . . PROP. LINE <br /> FOUNDATION _Q _ AGRICULTURE W 01HER WELL._... PIIS/SUMPS Ak <br /> INTENDED USE _ _TYPE OF WELL PROBLEM AREA CONS rRUCTION_SPECIFICATIONS <br /> � it <br /> 0 Industrial O Open Bottom O Manteca Dia o Well Excavation_ Dia. of Well Casing <br /> M Domestic/Private Ll Gravel Pack O Tracy Type f Casing_ 1� C Specifications ,70 5444 Fh`k <br /> I'I Public 04 OtherS)k"'A?a0-K'n Delta Depth-of Grow Seal 2 Type of Grout Of-01�^ <br /> I 1 Ifrioation 1?!Approx, Depth I I Eastern Surfacti Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ _ <br /> Well Destruction D Wall Diameter Z r+ _ Sealing Mate al i Depth Be#VIVA,j- �CT <br /> Depth r Piller Hater 1 i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will sorve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 tool: _ __ _ Water table depth <br /> SEPTIC TANK Q Type/Mfg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Fou anion_ Property Line <br /> LEACHING LINE CI No. 6 Length of lines _ _ Total length/size _ <br /> FILTER BED I.-I Distance to nearest: Well Fou aetron Property Line <br /> SEEPAGE PITS 11 Depth _ ._._Size �__� _ Number <br /> SUMPS LI Distance to nearest: Well Foundation_� Property Line <br /> DISPOSAL POr DS UJ <br /> 1 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 /> ruts and regulations of the San Joaquin County <br /> Home owner or licensed"ant's signature certifies the following: "t certify the, in the performance of the work for which this permit is issued, I shell not <br /> "toy any person in such manner as to become subject to workmen's compo salion laws of California." Contractor's hiring or tub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which 11 ds permit is issued, I shall employ persons subject to workman's compents <br /> tion laws of California.,, <br /> The applicant must call required inspictions. Complete drawing on rev se side. <br /> Signed Xdate: <br /> FOR DEPARTME.T USE ONLY �e <br /> Application Accepted by � Date r s Area <br /> Pit or Grout Inspection by _ Date inal Inspection by_ Onto <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public He ilih Services <br /> Environmental Health Permit/ ervices � / P <br /> 445 N.San Joaquin,P.O.Dox 88,Stockton,CA 95201-1388 <br /> NFO EE AMOUNT REMITTED CASH {! -RECEIVED 8Y DATE PERMII'NO.IF <br /> car <br /> EN Y].N tREV.I/A!; O 1 K O �' 1 I ~.-_ 00L0_?00 <br /> =r '. <br />