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APPLICATION <br /> r 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE VI , <br /> IC <br /> ENVIRONMENTAL HEALTH DIVISIO # <br /> k. 445 N SAN JOAQUIN,PHONE(209)469-34120_ 0 <br /> P O BOX 388,STOCKTON,CA 95201-0388 ' • # <br /> PERMIT EXPIRES 1 YEAR FROM DAT ISSUED <br /> (Complete in Triplicate) CgC6/ <br /> 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 with San <br /> Joaquin County Development Title Section 9AI 110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> t. Q <br /> Job Address a / -, Q C', Lot Site/ re IAZA U <br /> WeOwner's Niz�4Address 7�J .!i Pone <br /> Conlrac or Address X 10 &X 27/ f4�•License Nq 37% 26� Phone 4/ I ID <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑P Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL p-iNix, (I U1 <br /> 'rS, p�-`!/ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A <br /> \ <br /> C 1O <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation r..PUAaQ�� JCfsT <br /> ❑ Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing_ — C7p-1R0N���a ' BN.. <br /> I'1 Public <br /> El 1­1 Delta Depth of Grout Seal - ;TyPW_ yy <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by C <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Wail Destruction ❑ Well Diameter Sealing Material L-Depth - <br /> r. Depth _ Filler Material i Depth <br /> P ( <br /> TYPE OF SEPTIC WORK: NEW INSTION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public"wet is. <br /> 7 available within 200 feet:l <br /> lix, Installation will serve: Resid/ante_ Commercial_ her <br /> Number of living units: _L Number of bedry n� <br /> Character of soil to adapt of 3 feet: Water table depth- P( <br /> ` SEPTIC TANK Type/Mf Capacity No. Compartments <br /> PKG. TREATMENT PL ❑ / Method ofccDitp�sal. <br /> Distance to nearest: Well Frorindetioq__ /D. Property Lina.-.� <br /> I � <br /> tr LEACHING LINE No. d Length of lines — Tgtal length/size <br /> FILTER BED ❑ Distance to nearest:� Well Foundation Property Line �t <br /> y SEEPAGE PITS �.r Depth Site ,,��,�,,,, yumber <br /> SUMPS LI Distance to nearest: Wall J--!!-C.` Foundation (Q� Property Lina�L <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'"gnalure csrtifles the following: "I certifythat 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 compensatiori laws of California." Contractor's hiring or subcontracting 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 C If is " ' <br /> The applicant t call for zQR qu d inspections. Complete drawing on reverses d <br /> Signed ills: Date: 9 <br /> ' FOR DEPARTMENT USE ONLY •n1 p Ls, <br /> Application Accepted by�}Ly3�_, 1�A+�"�L+� Date 1�S— 1 l/J Area Al� f <br /> � �''t�or Grout Inspection by a-4.teFinal Inspection by <br /> Additional Commsna: �,�� r/�/1-Z 1• J 7 <br /> s uT. atT <br /> 11 <br /> Applicant - Return all copies to: San Joaquin G6Jty Public Health Services �L <br /> Environmental Health Permit/Services <br /> .1�t 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 <br /> (.� FEE AMOUNT D�UEE��/ AMOUNT REMITTED C K RECEIVED BY t DATE PERMIT'NO. /'l✓ m <br /> SEN t}24(REV.vnel J I ' � / i- n y <br /> f ✓I u 2 <br /> FN 11-a1 i <br />