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APPLICATION FOR PEPWIT <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 , STOCKTON, CA 95201 � t � <br /> 41 <br /> P <br /> (Complete in Triplicate) '. <br /> Application is hereby made to Ban Joaquin County for a permit to construct rLnd/or install the work herein described. This <br /> application is a@Ae in compliance with Bas Joaquin County ordinance ga. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. f •j1 j ' .�j 7G ��I <br /> _ 3f Lot Sizc/AcreaBc % <br /> Job Address City <br /> 'rill, L (�f'' Phone ) " <br /> owner's Name Address- <br /> �., c <br /> Contractor - ,I !: `� Address <br /> C J' License No._ �r L.L J-_Phone <br /> TYPE OF WELL/PUMP• NEW WELL WELL REPLACE ENT Cl DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER <br /> Monitoring well C3 <br /> DISTANCE TO NEAREST: SEPTIC YANK SEWER LINES DISPOSAL FLD. "-OL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t. <br /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation 9 Dia. of Well Casing <br /> 1-1 DomezliclPrivate �g Gravel Pack 10 Tracy Type of Casino___ Specifications <br /> 11 Public 171 Other n Delta Depth of Grout Seal �-.,,,...j(-n Type of G cxli <br /> )i kr anon Appres, Oapth I I Eastern Surface Seui Installed by ,�� & -- <br /> Repair Work Dona L3 Type of Pump K.P. State Work Done <br /> Wall Destruction 0 Wall Diameter sealing Material I+ Depth <br /> Depth Filler Material S Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 flet.) -A <br /> instailatlon win carve. Residence_ Commercial _ Other <br /> Nutttbm of raving units: Number of bedrooms PAYMENT <br /> 0wacteir of saa to a depth of 3 feet: Water <br /> VL <br /> SEPTIC TANK 0 Type/Mfg Capacity No. C <br /> PKG. TREATMENT PLT. 0 MothoMsA <br /> Distance to nearest: Well Foundation Property _11. OUNTY <br /> LEACHING LINE 0 No. b Length of lines Total langt"A , <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line} <br /> SEEPAGE PITS I I Depth Sire Number - <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> l hereby canify 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 signaturo certifies the following: "I cenify that in the performance of the work for which this permit is issued, t shall not <br /> employ any parson in such manner as to become subject to workman'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 parmit is issued,I stall employ persons subject to workman's compensa- <br /> tion laws of CARfornla." <br /> rtq <br /> The applicant st call for aA requirP63nspections. Coto drawing onverse sine.:!- <br /> SiTifle: �.- ��,arr <br /> ;OR DFPAflihiENT USE ONLY a� <br /> Application Accepted by c ' ft-cam Data Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat4. L <br /> Additionst Comments: <br /> Applicant - Return all copies to: San Joaquin County Public stealth Services <br /> Environmental Health Permit/Services <br /> 445 N Srsn Joaquin„ O boa 1009, Stkn, CA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NA. <br /> INFO <br /> r�� J/ ' <br /> . FN t3.2a(REV.s w si r.61 �. Vii' Tn - . <br /> E>t 9{-]e <br />