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APPLICATION �f <br /> SAN JOAQUIN COUNTY PUBLIC HEALT &R# ' ` 1 <br /> ENVIRONMENTAL HEALTH DTVI Q T <br /> 445 N SAN JOAQUIN, PHONE <br /> P O BOX 2009, STOCKTON, CA �5? # s <br /> PERMIT FMIRES I YEAR FROM DAT�I <br /> (Complete in Triplicat ) i. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or ittatsll the work herein described. This <br /> application 1a rade in compliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations or San <br /> Joaquin Count 1c HeJob Address ��,xx Ci alth SeTvlc <br /> 31 `/j�. Lot Slie/Acrerge <br /> ' ■�""� --� — <br /> Owner's Name^ Addre3 �Y OD to� __ phoneO7r/r��+�� <br /> t.. <br /> Con tractoll� v s � M' -_AddresaoM a 14�Cb1a wa� License N ����"' PhoAe�`� � <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT Fl DESTRUCTION 0 Out of Service Well Q <br /> PUMP INSTALLATIO SYSTEM WAIR -111Nonitoring Well U <br /> ] OTHER ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES ~1 fy DISPOSAL FLD. PROP. LINE S <br /> FOUNDATION _ AGRICULTURE WE L OTHER WELL PITS/SUMPS ,\ <br /> INTENDED USE TY E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial Open Bottom D Manteca Dia. of Weil Excavation, Dia. of Well Casing <br /> f+.t'bomestic)Private 0 Gravel Paek !7 'Tracy Type of Casing Specifications ­41) <br /> I'I Public F1 Other fl Delta Depth of Grow Sea; 14001 Type of Grout <br /> I i Irrigation _Approx. Depth ' I Eastern Surface Seel Insulted by •�•—= (� <br /> Repair Work Done L7 Type of Pumper i,P, ____ State Work Done <br /> Well Destruction O Well Diameter Selling Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION + I REPAIR/ADDITION I I DESTRUCTION I ; 1No septic system permitted if public sower is <br /> available within 200 leet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. JAIEE {�( <br /> PKG. TREATMENT PLT.0 Met"REeMED <br /> Distance to nearest: Well Foundation Property Lin UN 2 "ml. <br /> LEACHING LINE Cl No. & Length of lines � Total length/si N j A UIN COUNTY <br /> FILTER BED CI Distance to nearest: Well FoundationPr HEALTH SERVICES <br /> — �tTN DIVISION <br /> SEEPAGE PITS 11 Depth Silo Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this, application and that the work will be done in accordance with San Joaquin county ordinances, two laws, and <br /> rules and regulations Of In$ San Joaquin county <br /> Horne owner or licensed agent's signature certifies the following; 1 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*hall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applies t must all for al red inspections. C mplate drawing on reverse side. <br /> Signed X_ Title: (al)MAL Date: f_/Z) <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Ana <br /> Pit GJ)ispeetion byJ vpPK Dave b� 9 Final inspection by Data <br /> up�. .ti.� afE-�ad`� <br /> Additionoi Comments: ,'Dct ss c-F - ' � <br /> ct w r A Mr <br /> - ss <br /> Applies t - Return all coi S to: San Joa uin County Publi�lth Services <br /> l Environmental Health Permit/Services -,r-yw IrIlolly <br /> Ylti 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED C SH RECEIVED 8Y DATE PERMIT NO, <br /> D <br /> EN13-7a IREV ri�si co /�7 '� ���t.J� <br />