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APPLICATION <br /> SR # � .. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH5ERVnICES <br /> ENVIRONMENTAL HEALTH DIVIS Q�1 U # _ri �_ oL4 N <br /> 445 N SAN JOAQUIN,PHONE(209)46 -Urc <br /> P O BOX 388,STOCKTON,CA 95201 is <br /> P EXPI l Y FR D T <br /> (Complete is Triplica j <br /> Application is hereby mode 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 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address 0 Vn City �L,!`d i Lot Size/Acreage <br /> Owner's Na foilQ, 1 64' d- 141 Address !%:3-_71 - C t� Phone <br /> Contractor IM `t if L i^" Address �� License No, Phone ` <br /> .� g)- <br /> TYPE OF WELLIPUMP! NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Veil D <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER,LINES DISPOSAL FLD- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W"I.L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Induslrral D Open Bottom 0 Manteca' {Iia, of Well Excavation -----1Fe t, �ad►lg <br /> (a Domestic/Privale 0 Gravel Pack C] Tracy Type of Casing_ (i <br /> I'I Public - 1.1 Qther . f-I Delta Depth of Grout Seal Tye o�a V <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal InstallWd by TNZ 22 f <br /> Repair Work Dona U Type of Pump H_P- ( , <br /> f3calitts i+latarial i Depth State work�fit�el�tAr�6iN j3e�e#�a�tt <br /> Well Destruction 0 Well 6'am" eter 96P i4 S <br /> Depth_ Tiller Materiel h Depth ENMON1MENIAi_FUER/ ,�i TW f�li I-+DIVISION <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION`+I'" REPAIR/ADDITION f I DESTRU TION l I (No septic system permitted if public Sarver is <br /> A� available within 20D leer.1 <br /> Installation will ttarve: Residence— Commercial I.-- Other <br /> Number of living units: Number of bedrooms _- Z� <br /> Character of sod to a depth of 3 test: Water table depth <br /> SEPTIC TANK 9111`iypa/Mf2 Q arc '��i- ._ Capsc)y am No. Compere. me <br /> PKG. TREATMENT PLT. C] /�'t�'fPs Method of Disposal <br /> Distance to nearest: Well_ Foundatice ___ Propanty LOW <br /> LEACHING LINE P.—No. S Length oti lines Total lengthlsize <br /> FILTER BED Cel Distance to newest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size Number_ <br /> SUMPS U Distance to nearest: Well�_ Foundation Properly Lina <br /> DISPOSAL PONDS 0 <br /> I hereby certify that 1 have prepared this application and that the Work will be done in accordance with San Joaquin county ordinances, state sews, and <br /> rules and regulations of the San Joaquin Couaty <br /> Boma owner or hennaed agent's signature cenifies the Ionowing: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any parson in such manner rim to become subject 10 workman's compensation laws of California."Contractor's hung or sutrcontraciing signature <br /> certifies the following: "I certify that in the performance of the work-for which this permit is issued,I shall employ persona oubjeat 19 workmanrecompensa- <br /> tion laws of Calilomlo." <br /> The asiblicant must call for ati required inspections- Complete drawing on reverse side. <br /> Signed�_�2f $f l;iY.u✓ Title: 1[.d/ re Date: )1VC7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date AroIce /P�c' <br /> Pit or Grotrt Inspection by Date Finsi Inspection by Data <br /> �1 <br /> Additional Commonu: f��'t <br /> Applicant - ileturn all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Scrvices - <br /> 445 N.San Joaquin.P.O.Box 388,Stockton,CA 95201-OMS 2ir <br /> tFEEAMOUNT DUE AMOUNT REMITTED NFO CAH AECEvko HY DAT.11.74( v . e i '` 1141i 0-0 11-Lk 0(Jf- a <br /> tN 141a <br />