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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> WMIRONMENVAL.HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (20R)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> Y <br /> (Complete in Triplicate) <br /> Applic"" is hereby made to Sett Joaquin County for a pemit to eanstruct and/or install the work herein deacribed. This <br /> application Sb made to complia$ce with $an Joaquin County ordimmes No. 549 and 1862 and the Rules call Ragulatioee of Bao <br /> Joaquin County public Health Services. <br /> e <br /> XJob Address " City�&w 14t else/Acreage IV <br /> ti �1�['� • <br /> ffo-nees Name �/ L _'�'`p'� ddress a �/ • + at <br /> S Phone <br /> ---�� ' a�� .ice .� �fs <br /> antraclor_ Address License No, Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Cl Out of Service $tell, <br /> f UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well. n <br /> DISTANCE tO NEARESt., SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE <br /> FOUNDATION AGRICULTURE LVELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom ❑ Manteca bre. bf Well Excavation bra. of Wap Casino <br /> 0 DomeaftiPrivate ❑ Gravel Pack 0 Tracy Type of c6sh, _ <br /> I'I P16k specifications <br /> [I Other . 1"I,Delta Depth of Grout Seal Two of Grout f �� <br /> I I trrrgadar5 Approx. Oepih I I Eastern Surface Said Installed by UJ <br /> Repair Work bond 0 Type of Pump _ - H.P. 'State Work Done <br /> Well Destruction D Well Diameter sealing Material i Depth <br /> Depth tiller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I I Wo septic system permitted it public sewer is <br /> Installation will serve: Residents____, Commercial_ other available within 2W feetJ <br /> Number of living units: Number of bodrooms <br /> Character of loll to a dapih of 3 taatt <br /> Water lobo depth <br /> SEPTiC TANK <br /> Ck TypelMlg Capacity No. Compartment$ ' <br /> PKG. TREATMENit PLT.C7 Method of Disposal <br /> Distance to nearest: Wdll Foundation Property Line <br /> LEACHING LINE Cl No. S Length of pnas Total lengt#i/sire <br /> FILTER RED O Distance to nearest: Wed Foundation. Property Line �_ 1► <br /> bt <br /> SEEPAGE PITS II Depth Sire Number <br /> SUMPS 0 Distahce tb nearest: Wall Foundation f <br /> DISPOSAL PONDS ❑ ProPeny Lina- -- <br /> I hereby certify that i have prepared this application and that the work will be done in accords with San Joaquin county ordinances, stele saws,and <br /> rules and regulations of the San Joaquin County nc <br /> Home Owner of IkNtead agent's alonature certifies the following: "I certify that In the performance of the work for which this permit 1$Issued,I shall not <br /> employ any person in such manner as to bftomi subject to workmen's tompenlalion taws of California."Contractor's hiring or sub conerectlhq signature <br /> certifies the following;"I certify that in th8 W0rmence of the work for which this permit is issued,1 shall em # <br /> tion laws of CeNfomia." employ parsons subject to workman's CompMp• { <br /> The applicant must cad for ell required Inspii.J00nt. Complete drawing on reverse side <br /> rBned Title; <br /> Data: <br /> D PA/tTM[`NT USE ONLY r <br /> Application Accepted by _ - Date 2- <br /> Pit <br /> Pit or Grout Inspection by <br /> Date Final Inspection Date _ <br /> Additional Comments; -1 ALL <br /> I` <br /> Applicant » astute-all copieA to; 8Rn J04gdle Couat'y Public Health Servicea { <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2008, Stkn, CA 95801 <br /> FEE AMOUNT DUE AMOUNT NEMtT'TE0 <br /> INFO CASH RECEIVED By DATE PERMIT-NO. <br /> Co ed <br /> r <br /> .t <br />