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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p <br /> xUVIRONMENTAL HEALTH DIVISION 0 <br /> 445 N SAN JOAQUIN PHONE (209)468-3420 <br /> 14 <br /> P 0 BOX 2009, STOCKTON, CA 95201. <br /> lRX� ' t <br /> " ► aF�IT E%PIRBS 1. Y�SAH FROM DATF ISSUED <br /> (Complete In Triplicate) <br /> Joaquin Count for a permit to construct and/or ictstall the work herein described. Sans <br /> Application is hereby cede to San Josef Y <br /> application is made 11cnHea�thiServicesh Batt Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Re <br /> Joaquin County <br /> Lot Si"/Acreage <br /> City <br /> XJ,b Ad-drillss I L&-D— Phone <br /> �,�' {� -- Address r <br /> tyPE <br /> r's Name e <br /> License No. Phone <br /> Address <br /> actor► WELLR-PLACEME T n DESTRUCTION Cl Out of Setviee Well O <br /> Of YVELLfPUMP_t� NEW WELL ❑ OTHER O Monitoring Well <br /> /-PUMP INSTALLATION SY57EM AIR ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> R <br /> DISTANCE TO NEAREST::FOUN SE LlNE5 <br /> TANK -------- AGRI LTURE LL OTHER WELL <br /> PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTION SPECIFICATIONS_ '� <br /> -- of Well Excavation Ore. O}1�e11 Casing <br /> O Open Bottom ry(] Manteca <br /> C? Indusuisl Casing---- Specifications <br /> -❑ Gravel Pack —.al ❑.T y- - Type ng_a-- <br /> n Domestic/Private; t Depth of t Seal Type of Grout <br /> Il Public <br /> . (_1 Other <br /> I I Inipation Approx. Oapth, e?'n "" SuiftCe Seal"► d by <br /> ' , <br /> � care Work Done <br /> [� <br /> Repair Work Dont ' Type of Pump H.P.H.P_ Sealing-Material &,Depth \ <br /> Wail Destruction 1 O Wad Diameter <br /> Filler Material & Depth <br /> Depenseppermitted if public wwe+ is <br /> �111111111TYPE OF SEPTIC WORK:f NEW INSTALLATIO REPAIR IADDITION I I QEST�CTIO I ! t ave able system pe p <br /> available within 200 feet.i <br /> — Commercial_ <br /> the(' ;�i� <br /> Installation will some: Residence_ ' f <br /> Number of living units: _� _,. Numbercof bsdroortt>< <br /> •,,, Water table depth <br /> Character of soil to a rda1 <br /> 1pth of 3 feet: - No. Compartments <br /> yp <br /> SEPTIC TANK Te/Mf ' Capacity' <br /> ,�;r;, g - I r Method of Disposal <br /> PKG. TREATMENT`VLT;.D roperty Lina <br /> i Divienee`to nearest }(Wed ` oundation <br /> No.'& len thll f lines Total length/size <br /> LEACHING LINE 9 /" Property Line <br /> FILTER BED n "Distance to nearest: Wall b_ Fourtdetion -. <br /> -mow 4 <br /> SEEPAGE PITS I 1 •Depth ` Sue y� f Number <br /> SUMPS t � Lt r Distsnce.ta nearosr" Well Foundation <br /> Property Line <br /> DISPOSAL PONDS O { <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 /> rubs and regutstions of the San Joaquin County <br /> Contractor's hiring <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the oarce of the work for which this pernvt is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws <br /> of of C California.'" c sub-contracting signature <br /> wing:;'t certify that in the pertormsncs of the work for which this per is issued.(shall smpby persons subject to workman's compenaa- <br /> lion Iavw of Geminous.-F <br /> The applic t ad required inspection Comps to drawing on reverse side. <br /> s� <br /> nod +� Title: r y:.J P_ Date: <br /> D Y ___1_ <br /> Date Ara ro . <br /> App►ication Accepted by M 7 - t <br /> (h2t41 _ Dats Ls <br /> ' Pit a(trout inspection by Date Final Inspection by <br /> i 4 <br /> � t t <br /> Additional Comments: <br /> App l4icant - Return all copies to: San Joaquin County Public Health Services <br /> linviroamental Health Permit/Services <br /> 445 N San Joaquin, P ox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K ED BY O TE PERMIT'N0. <br /> k EN 13-24IREV.+iee /, S ✓�f / <br /> EN 70,20 <br />