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APPLICATION ccee # <br /> - ^s- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S VIC !Z �� <br /> ENVIRONMENTAL HEALTH DIVISION Allyl <br /> 445 PN OSOXJOAQUIN, PHONE 2009, STOCKTON, CCA)952 1?AC # <br /> PERMIT EXPIRES 1 YEAR FROM DATE I # <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se vices. <br /> G <br /> Job Address V O '� ` r d City _ & Lot Size/Acreage <br /> Owner's Name �. Address '� - Phone 1 U /+ ^ <br /> y Contractor Zff ani ress ��� icense Noy <br /> Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER F_ Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D POSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ow INTENDED USE TYPE OF WELL PROBLEM AREA CONSJ,ng_ <br /> ON SPECIFICATIONS <br /> L-3 Industrial ❑ Open Bottom ❑ Manteca ZDiafxcavation Dia. of Well Casing <br /> N Domestic/Private D Gravel Pack Li Tracy __ Specifications <br /> i1 Public Fl Other 1-1 Delta Depth of I <br /> rout Seal Type of Grout Vti <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Sedl Installed by (/1 <br /> Repair Work Done i] Type of Pump N.P. _ State Work D e ` <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material Z Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No �,p,��cyy�� rMjr�Vub6c sewer is <br /> Installation will serve: Residence Commercial Other CCCSSIIL.. HV���3 <br /> ENVIRONMENTAL HEALTH DIVIgIpN <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4 6 01 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg JV "4y_ jA,144 ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �+ Method of Disposal <br /> Distance to nearest: J Vk- Fpundation <br /> foperty Line aCi <br /> LEACHING LINE Cl No. 8 Length of lines - Tot i ngth/size <br /> FILTER BED CI Distance to nearest: Well oundatton Property Line <br /> SEEPAGE PITS ( I Depth e Fo __ mer <br /> SUMPS LI DDjstance to nearest: I <br /> Property Line <br /> DISPOSAL PONDS ❑ r <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'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 /> 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 California." <br /> The applicant m till for alf r fired inspec ions. Complete drawing on reverse side. <br /> Signed X Title: C1Yl,�-'1 Date: ��" <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C . Q Data <br /> Area <br /> Pit or Grout Inspection by its <br /> Date ! Final Inspection by Date y 2 <br /> -Q" g. �I}� <br /> Additional Comments: XC [ , Q e" . ,,- --- b r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CKSH RECEIVED By DATE PAkMIT NO, <br /> EH U.�IREV.rinsr r� �- 1 kl�,. lI v L[/ 1-3/0 <br />