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APPLICATION <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC SERVICES .�J M <br /> ENVIRONMENTAL HEALTH <br /> HONE (�08-3420 U�3 <br /> 445 N SAN JOAQUIN, � 9 <br /> p O BOX 2009, STOCKTO , <br /> ERMIT EBPIR 1 <br /> S _LEAR FRI111" Q/ q <br /> (Complete in Tripi EJ 1 l 1 <br /> This <br /> Application Se hereby made. San Joaquin County for a permit to const <br /> application Se lade in coetpllance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of en <br /> Joaquin County Public Health Serwlcea. Lot Size/Acreage 5--- <br /> City S��u <br /> I i <br /> Job Address ..r2 L4- <br /> ++ �n G. ,g Phone --,2.3 <br /> QtQ14 V Ult� Address _---"�-5.�.-���- <br /> DWMr'a Name - / <br /> Le -S4x <br /> Address � icense No. 0 7put <br /> Ser -� <br /> NEW WELL ❑ vice Well O <br /> contractor RUCTION monitoringWell <br /> Q <br /> EL/ WELL RELCOTHER O <br /> SYSTEM REPAIR E <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PITS/SUMPS <br /> FOUNDATION PROP. LINE <br /> SEWER LINES / <br /> DISTANCE 70 NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL V_ <br /> '�— <br /> INTENDED USE TYPE OF WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS O . of Well Casing <br /> Dia. of Well Excavation <br /> Cl Industrial O Open Bolton <br /> Type of asmg_ <br /> FI Domestic/Private ❑ Gravel Pack C <br /> ❑ Tracy Type of Grout <br /> (:1 Other 71 Delta Depth of Grow Seal <br /> I'I Public — Surface Seal Installed by <br /> I Intuation ApMos. Depth 1 Eastern State Work Done ._ <br /> ! Type of PUMP H.P. <br /> Repair Work Done U Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material i DepthDepth <br /> available within 200 feat.) . <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permuted it public Sewer w o <br /> Other !. <br /> t <br /> installation will serve: Resi)de�ce Commercial _R ff Ir <br /> Number of living units: Number of Oedrtwms <br /> I �•- Water table depth ' <br /> Character of spit to a depth of 3 feet: Capacity /4.ffX2, No. Compartments tr <br /> SEPTIC TANK -Type/Mfg „ s <br /> Method of Disposal- <br /> PKG. TREATMENT PLT. ❑ ..--/� <br /> Distance to nearest: Well --itv='Foundation 0 Property Line <br /> 0 <br /> Total length/size A <br /> LEACHING LINE �- No. g Length pi lines ^�^ Property Line <br /> O Distance to Merest: Well _[S Foundation�i i <br /> ` FILTER BED <br /> Izti` r Sire Number <br /> SEEPAGE PITS )C- Depth Foundation�2Q--- Protxny Line L"�" <br /> SUMPS LI Distance to nearest: Well Well - lJ <br /> DISPOSAL PONOS O <br /> I hereby certify that I have prepared thi8 application anou <br /> d that the work will be done in accordance with Sen Joaquin cnty ordinances, elate laws, an <br /> not <br /> rules and regulations of the San Joegwn County _ <br /> Home owner or licensed agent's signature cenilies the following: "I certify that in the pertormence of the 'work for which thin r jub-c a issued.-I.snail signature <br /> employ nsation <br /> certifroatha following!��lccert manner <br /> that <br /> n the performance of become-subject-to <br /> workforwh ihth s permtWs,lssuediloehalt employ aPeraonscitorii lsubjact to workman's companee <br /> tion laws of California." <br /> The applicant mus ap for all to i ed nspections. Complete drawing on reverse side. <br /> //! � Title: Data: �---� <br /> Signed Y <br /> r FOR DEPARTMENT USE ONLY <br /> Date � ( 9-�J Area (��,1 <br /> ` AppllGtion Accepted by '� Date <br /> 6)01 <br /> 1 Date �� nal Inspection by <br /> or Grout Inspection by � <br /> 1 Additional Comments: in <br /> I Appllcanl, - Return all copies to: San <br /> Environmental oHeal thuPerml t/8ervlcesHealth v Services <br /> 1 445 N San doaquln P 0 Box 2009, Stkn. CA 95201 <br /> CK RECEIVED BY DATE PERkNO, <br /> niE <br /> MOUNT REMITTED <br /> . EB13 24 Ig EV.vn» <br /> FR ta.M <br />