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APPLICATION <br /> ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> .� P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San 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 /> Josqula County Public Health Services. <br /> SLS s. rp t � A� IQ <br /> Job Address 'P,A ,1s�1�v1 City�r'LyA��'� Lot Size/Acreage _�c <br /> Ownei s Name�r i C'�cks.�MQh'Add'rV ss ���. ar , i of /c -t Phone <br /> Contractor Address 4p2-91 / nC92 O f / License No L Phone 72` <br /> TYPE OF WELL/PUH : NEW WELL ❑ WELL REPLACEMEN DESTRUCTI t of Service Well ❑ <br /> PUMP INSTALLATION 79. SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> ma INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q { <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavates Dia. of WON Casing D <br /> `1<6onrstic/Private Gravel Pack ❑ Tracy Type of Casing Specifications r <br /> 1'1 Public /11 Other�C fT Delta Depth of Grout Seal Type of Grout a�� <br /> I I Irrigation Z�ZfL Ap <br /> X. Depth 1 I Eastern Surface Soul Installed -, �m's�'T <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> �u Sealing Material & Depth r <br /> Wall Destruction Well Diameter �+� <br /> - Depth 11 Filler Material i Depth k, `10 r ( fvst <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted it public sewer is <br /> 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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> _ LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS If 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies 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 compensa. <br /> tion laws of Calit or <br /> The applicant mu c for dirt coons. C21DRIuWdrawing on reverse aid / <br /> Signed T 11. 41 Date: 7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by u ��p�p: Date Area 711 <br /> Pit o rou Inspection by Date vi n,� Final Ins tion by Date <br /> Additional Comments: &AW �Ajf! ✓ <br /> Applicant - Return all copies to: San Joaquin County Public Hea1A Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INEE AMOUNT DUE AMOUNT REMITTED CKA CASH RECEIVED BY DATE PERMIT'NO. <br /> FEM N ir.m(REV,v n 5)ur 1 awe C! t7_1 <br /> T CP­ � .r.. <br /> a— i _ -91 6— k 12&17 8.2-2363 <br />