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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALT 9V GAS �i/ <br /> ENVIRONMENTAL HEALTH DIVI {} <br /> 445 N SAN JOAQUIN, PHONE (209 #2u— qft <br /> P O BOX 2009, STOCKTON, CA �q7u <br /> PERMIT E%PIRES 1 YEAR FROM DA E l� tt <br /> ` (Complete in Triplicat ) — 0114 <br /> Application is hereby mode to San Joaquin County for a permit to cons truct.and/or inatall the vork herein descr, <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> LJoaquin County Public Health Services. <br /> Job Address 33S70 �4ZfYD City�� Lot Size/Acreage <br /> L Owner's Name r Address <br /> ��T��'t�� �--� Phone V <br /> License S�i Z Phan y t' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION Cl Out.of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 2 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> L INTENDED USE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial OOpen Bottom ❑ Manteca Dia. of Wall Excavation Dia- of Well Casing <br /> L omestic/Private ❑ Graver Pack ❑ Tracy Type of Casing_ Specifications <br /> I"I Public CI Other tl Delta Depth of Grout Seal Type of Grout <br /> - <br /> I I Irrigation /_Approx. Depth I I Eastern i Surface Seal Installed by <br /> Repair Work Done Jd� Type of PumpH.P./1-- State Work Done <br /> Well Destruction O Well Diameter Sealing Material L Depth W <br /> 61 Depth Filler Materiel 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) O <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: y(attaqar table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity g12yo <br /> PKG. TREATMENT PLL ❑ .. a�a"��g�^d s ( {}�� <br /> Distance to neerest: Well Foundation Proprte `p4 ° <br /> a�rtt <br /> n P11 j�D LI <br /> LEACHING LINE ❑ No. & length of lines Total%Str�e�aAQ1� <br /> FILTER BED 0 Distance to nearest: Well Foundation ENVIP,P,dppy - bTHAs <br /> I LTH incl"f�tti <br /> SEEPAGE PITS I 1 Depth Sire 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 /> am rules and regulations of the Sen 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 sub-contracting signature <br /> canities the following: "1 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 California." <br /> a' The applicant mu IhfLJ ell requirad�inspecli0 S. Complete drawing on reverse side. L <br /> Signed X Title: rte- Date' <br /> VFOR DEPARTMENT USE ONLY <br /> Application Accepted by �1MSDate / f Y- / ( 7`— Are /A <br /> L Pit or Grout Inspection by — i Date Final Inspection by !11!Ni`�qAa—fn)' � ��9!� <br /> Date's- <br /> —Y- <br /> Additional Comments: <br /> L Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 3 0/V 445 N San Joaquin, P O R_oa 2009, Stkn, CA 95201 <br /> NFO AM UNIT DUE AMOUNT REMITTED CKX�/,/'I RECEIVED BY OAT PERMIT NO. <br /> Ltt-zr laEv_rrasr '� Q'7� <br /> EN {la! /w J <br />