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APPLICATION D <br /> SAN jOAQUIN COUNTY PUBLIC HEAL Q t iCBS <br /> ENVIRONMENTAL HEALTH DIV SI 1�� _ <br /> Uva 445 N SAN JOAQUIN, PHONE (209 20""" <br /> Q(o tom- <br /> -� P O BOX 2009, STOCKTON, CA <br /> YAL <br /> PERMIT MIRES I YEAR FROM DA E" i`5! <br /> AM <br /> (Complete in Triplicat )INV # ,.�...�SS. <br /> Application is hereby made.to San Joaquin County for a permit to construct and <br /> application is made in ceupliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> 3 2 ty Ci --At Size/Acreage <br /> Job Address <br /> Owner's Name <br /> Address — Phone <br /> Contractor_ ��2� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT M DESTRUCTION Cl Out of Service We12 C❑3 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I"I Public I:1 Other I71 Delta Depth of Grout Seal Type of Grout <br /> t i Irrigation Approx, Depth t 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Dona_. <br /> Well Destruction © Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I NaailabPeic tw thin 200 feet�Iad <br /> rl public sewer is <br /> Installation will serve: Residence— Commercial— Other P� <br /> Number of living units: Number of bedrooms Y ["j; <br /> Character of soil to a depth of 3 feat: �"" <br /> SEPTIC TANK ❑ Type/Mfg Capacity A No. is <br /> PKG. TREATMENT PLT.Ll RliRth�o[lQ�pOsal r <br /> Distance to nearest: Well Foundation Cp� - 9N CII:`Jl�y((�f <br /> LEACHING LINE C1 No. 8 Length of lines Total long gh f 0 <br /> FILTER BED n Distance to nearest. Well Foundation Property Line--- r <br /> SEEPAGE PITS i I Depth Site Number <br /> s SUMPS LI Distance to nearest: Well Foundation Property line <br /> ' DISPOSAL PONDS 0 <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 fegulalions 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 shalt 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 permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicany4Qst call for all requ'ed inspections. Complete drawing on reverse side. p <br /> Signed Xfi Title: mu✓Yl ��— Date: �' rp <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> i <br /> Additional Comments: <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, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED c&& RECEIVED BY DATE PERMITNO. <br /> INFO •��r <br /> K 14.2E <br /> EK13-241NEV.rixsi / �r �t <br /> Ef <br />