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APPLICATION �� �� / / _ <br /> 622 0 <br /> SAN YtAQUIN COUNTY PUBLIC A�, aRVICES t�Qaq <br /> ENVIRONMENTAL HEAL1`B' I��}d.�..�— — "'^�a�'� <br /> 445 N SAN JOAQUIN, PHONE ( 09�,�6�-3420 <br /> P O BOX 2009, STOC%TON, <br /> �Ih PERMIT EXPIRES 1 YEAR FROM D S Rlal <br /> (Complete in Tripli <br /> Application is hereby made to Had 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 /> Job Addres>� City- y< Lot Size/Acreage Lo E� <br /> Owner's Name Address ��[ <br /> ff Phone <br /> ",- icense No.� Phone931( <br /> Contractor AddresX337ir-- M/[ rt <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Vi [3i/ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. Stala.�N.ork Done <br /> Well Destruction ❑ Well Diameter Sealing Material �'�""' <br /> Depth Filler Material li " r ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION D"AVCjI(bN ktdfan septic system permitted it public sewer is ' <br /> y MMIICC VV available within 200 feet.) <br /> Installation will verve: Residencer'.1_ Commercial Other SAN JOAQUIN . ' <br /> Number of kving units: J— Number o N7p�,roo�msPUBLIC HEALTH SEI• '- !� i <br /> Character of soil to a depth of 3 feet: �"''� L ENVIRONMENTAL HEAL Tr. , Water fable depth 0 v <br /> SEPTIC TANK ❑ Type/Mfg Capacity / No. Compartments <br /> PKG. TREATMENT PLT.❑ _. Method of Disposal <br /> Distance to nearest: Well Foundation Propany Line <br /> LEACHING LINE Jf' No. g Length of lines Total length/size <br /> FILTER BED ❑ Distance to merest; Well Foundation + l f1 Property Lina 1 i57C— <br /> SEEPAGE PITS If Depth / Size r Number e-IV-L--9, <br /> SUMPS LI Distance to nearest .-- eli .� FoundapOn 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 certifies the following: "I certify that in the performance of the work for 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 sutrcontracting signature <br /> candies 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 compena. <br /> tion laws of California." /f7 <br /> The applicant must all Im all re/�t��"etf "rlipac(ons. Compl drawing on reverse side. <br /> Title: ( E c idJ Date: O <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date , Area 1 <br /> � qE �jrout Inspection by 'A 1 k Date Final Inspection by-5,-61- Oats <br /> VAdditional Commet <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> l!r� / 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> `j ,7 `/ IN AMOUNT DUE AMOUNT REMITTED CKrIj <br /> RECEIVED BY I D E PERMIT NO. <br /> . EN pax(ACV.v x el <br /> EN lx.aE at �(l <br />