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OCT 91992 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 P PeR�Q=q: <br /> 'PERMIT EUJRES I YEAR FROM DATE ISSUID <br /> (Complete in Tripd3ewl fn, P<%u, � Jailib �2 <br /> Application is hereby made to San lJoaquin County for a permit to construct and/or ins tall the v�if<q/11pie�n;'deacTJ•" Rhla <br /> application is made in ccaplimce,vlth Sm Joaquin County Ordinance No. 549 and 1862 and lite liaise �/R�gtalLi30a,A rof San <br /> Joaquin County Public Health Services. rli=% / '�'4 <br /> ® ^C1 <br /> (-J04) �' 1&AG 3z, City'4"'Tf/7 r Lot Size/A `\� - <br /> Job Address 7 <br /> • 1 <br /> �A^�A•f/r fJ( . Address R� �k q7& L 4 f'UC/ <br /> Owner's Marna <br /> Phone <br /> 1 I - S 2Z(1 Phone <br /> r Lonbauw Address F. �rzLlcense No.� ; <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION 7 Out of Service Well ❑ r <br /> ._.,PUMP INSTALLATION D. SYSTEM REPAIR ❑ �., _.OT ER.❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLl PRO <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS /✓ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Dpen Bottom 97 Manteca Dia. of WellExcjvaSon Dia. of Well Casing <br /> J <br /> 1.1 Domeslk/Private [�1 Gravel Pack D Tracy Type of Casing_ /oz 54wci1ications <br /> i'1 Public L & <br /> Ll Other I n Delta Depth of Grout Seal Type of <br /> I I Irrigation Approx.:0eplh I I Eastern Surfs" Seel Installed by :S;E� <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done <br /> A Sealing Material i Depth "V <br /> Well Destruction ❑ Well Diameter - <br /> Depth I Tiller Material g Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permilled if public sewer is 'd <br /> available within 200 laet.l <br /> Installation will sarw: Residence_� Commercial_ Other i <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 bet:f Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal <br /> 'Q`� <br /> Distance to nearest: Well Foundation Property Line p <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS1 I Dept.,- _... Size_ _--Number --------- <br /> SUMPS <br /> SUMPS LI Distance to nearest. Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby cenity(hat 1 have prepared this`application and that the work will be done in accordance with San Joaquin county ordinances, state laws. an <br /> rules and reguiadons of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> empby any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cenify that in the performance of the work for which this permit u issued, I shall employ persons subject to workman's compensa ` <br /> tan Laws of C rnio." l[ <br /> The applic nt mu t call for all r fired in 'ons. Complete drawing on reverse side. <br /> Signed Title: ,/ /A'/fi'1 Date: / L <br /> FOR DEPARTMENT USE ONLY / 9 i <br /> Application Accepted by Date / 7 Area <br /> Pit or Grout Inspection by Data Final Inspection by Date 2— <br /> Additional <br /> Additional Comments: I <br /> Applicant - Return ally'copies to: San Joaquin County Public Health Services 2q✓�a I <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> CKS <br /> INF(*OJ AMOUNT <br /> 1/DUE /� AMOUNT REMITTED /CASH RECEIVED BY / OA/T`E PERMITNO. ! <br /> EH I1N(RE .�i-I 1V0"D � <br /> EN a 26 tLV� <br />