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i <br /> APPLICATION <br /> SAN^JOAQUIN COUNTY PUBLIC HEALTH SE VICES . <br /> ENVIRONMENTAL HEALTH DIVISIO i 3 <br /> 445 N SAN JOAQUIN, PHONE(209)469-3 2?`'i <br /> P O BOX 388,STOCKTON, CA 95201-03 8F;:r1 .r..t <br /> Il PERMIT EXPIRES 1 YEAR FROM DAT I SSUID��" <br /> (Complete in Triplicate It <br /> I Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance w <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services, <br /> Joh Address �" � "' � �s�.X City Lot: Size/Acreage <br /> Owner's Name l Address Phone J � � <br /> Contractor _--_-S � Address License No. Phone <br /> h TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> �l PUMP INSTALLATION ❑ SYSTEM REPAIR [} OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST_: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i�_dleil Casing <br /> Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ pR'+�pp�i <br /> I'I Public 1-1 Other r Delta Depth of Grout Seal <br /> 7y dM1 }fCat�yf� <br /> I I Irtigation Appros, Depth I I Eastern Surface Soul Installed by ' ) t. <br /> Repair Work Done [J Type of Pump H.P. State f - rl� <br /> Well Destruction ❑ Well Diameter Sealing Material Z Depth <br /> DepthFiller Material L Depth <br /> TYPE OF SEPTIC WOflK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I t INo septic'system parmlitb a b�1G sewer is <br /> i/ available within 200 feet.) V/V <br /> y Installation will serve: Residence ^ Commercial Other <br /> F Number of living units: Number of bedrooms <br /> F Character of soil to a depth of 3 feet:F Water labia depth D ( <br /> SEPTIC TANK Type/Mfg Capacity b No. Compartments 7— <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. d Length of lines Total length/size <br /> FILTER SED Distance to nearest: Wall Founaation Property Line S� <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 canif es the following: "I certify that in the performance of the work for which this permit is issued, i shall not <br /> F,� <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 folio Ing: "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 laws of Ca�brnll.Tha applic ncalf fo r ed in~ tions. Complete drawing reverse s' a. IZZI <br /> Signed Title r <br /> Date. G� <br /> FOR DEP MENT USE ONLY <br /> Appiicatian Accepted by �a TYI(Gtt _ Dake ! R 9 Area ��6 <br /> ' <br /> F <br /> Pit or Grout Inspection by� DateFinal rnpection by Date/ <br /> _ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public lalthl Services <br /> t Environmental Health Permit/Services <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201.0388 v <br /> 5FEE AMOUNT DUE AMOUNT REMITTED' RECEIVED BY DATE PERMIT N0. <br /> r /f t' � / <br /> '/ INFO CASH <br /> E..-13•I4{AEv.IIA5J ae 11 <br />