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E NOUN <br /> APPLICATION �® <br /> SAN .JOAt4U1N COUNTY PUBLIC HEAL H l r <br /> ENV I RONMliNTAL 11FALTH D I`lS <br /> 445 N SAN JOAQUIN, PHONE (209 <br /> P O BOX 2001, STOCKTON, CA, 9562 <br /> PERMIT EXPIRES_.. YF_4R FROM D;,T rrhhllE VI !n?v <br /> (Complete in Triplicate) 'IV ff—-- <br /> Application is hereby made to Sen Joaquin County !or a permit to construct end/or Install the work herein described. This <br /> applleatica is made in compliance with San Joaquin County Or,llnance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /1 /n{ <br /> Job Address 7�/ �h -'-'--�----- �- C,tl�a—`-� �t Size/Acreage <br /> reege <br /> If lope, <br /> 2��,'�' y� a <br /> AdcLctis <br /> Owner's Name — Phone <br /> Contractor ddress 'LLicensNo. �42 'Phont�� <br /> Z7 <br /> TYPE OF WELL/PUMP. NEW WELL ;^, WELL REPLACEMENT it DESTRUCTION CT Out or Service Well Cl <br /> PUMP INSTALLATION G SYSTEM REPAIR L OTHER O monitoring Well D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F+_D. PROP. LIN° <br /> FOUNDATION AGRICULTURE WELL —_ OTI-:ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial U Open Bottom Li Manteca Ora of Wen Excavation Ois.o`f�W I Laing <br /> N Domestic/Private Ci Gravel Pack Il Tracy Type of Casing_._-_. P M t <br /> 1.1 Public 11 Other !I Datta Depth til Grout Seal <br /> I I Irrigation ___Apfuox. Dsplh I I Eaitem Surface Seal Insured by Y"1 <br /> Repair Work Done U Type of Pump `_ H P. _ State Work Done r <br /> Well Destruction Cl Well Diameter _ Sealing Material i Depth .�,t'�—CU <br /> ' Depth liner Material L D!pth t.Al•1 F1 pIViS�Gy <br /> TYPE OF SEPTIC WORK: NEW INSTAL REPAIR1ADDITIn DESTRUCTION INo f imilted if public sewer is <br /> available within 200 fest.) ml <br /> Installation vM1 serve: Residence_._ Cummerciel S_ OIMr <br /> Number of living units:_ Number of bmd:ooms__— <br /> Character of soli to a depth of 3 fee,: 4+L""^--r"L Water table depth <br /> SEPTIC TANK OType/Mfg ���QA�t Capacity-.2goo No. Compartments Z__ 7 <br /> PKG.TREATMENT PLT.Cl ; 1, Method of Disposal <br /> f <br /> Distance to nearest. Wed.2 r <br /> 0 0 Foundation�! Property Lina <br /> LEACHING LINE r� No.b Length of lines -- __ Total langih/size_5 <br /> /A <br /> FILTER BED Cl D,stince to nearest. We'll_ Foundation ��_ Property Lina <br /> _ten enc_ <br /> SEEPAGE PITS 11 Depth Site Number. <br /> SUMPS LI Distance to nearest: Well•_ Foundation Property Lina_ <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordrnsm:es,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";I not <br /> employ env person in such mennsr as to became eubrec!to workman's compensation laws of California."Contractors hiring cr sub-contracting signature <br /> camifies the following:"I certify thst fi the performance of the wo,k for which this permit is issued.I shall employ persons tubiect to workmen's compsnss• <br /> tion lows of California." <br /> The applicant((\\te�a call fol-a1 regmr ins ^rhos. Complete drawing on reverse side. r <br /> Signed X—1 �� *ue:—_ '� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area�1�-y7G1 ,p._.. <br /> /// <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: — <br /> t Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AIAOVNT DUE AMOUNT REMITTED CAIN RECE!V 9V DATE PERMITNO. <br /> INFO / <br /> 7 EM 1124 ta[v. FT <br /> ` � <br /> EX la•7 !1 <br />