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APPLICATION <br /> cR # <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEV, CES <br /> ENVIRONMENTAL HEALTH DIVI ONJ� _���_� <br /> 445 N SAN JOAQUIN, PHONE (209):6B���� ,,4 0 <br /> P 0 BOX 2009, STOCKTON, CA 12N14, <br /> PERMIT EXPIRES I YEAR FROM DAT IS3, <br /> (Complete in Triplicate <br /> Application is hereby mode 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 sad Regulations of San <br /> Joaquin Co=ty Puullc 1Health Services. <br /> Job Address �l Y �lJ���'( ��JPJ ---- City LoL Si2eJAcrea3e / �Ll�^�� <br /> Qwrter a Name fL �2 ��' fAress� `'z 1 J�/ }�'� �Cf� �5�?/ _7�Ph`one <br /> Contrattory J 'l Address%�Zdd� `h,,, f r License No.W-�! Phone w✓ 3� <br /> TYPE OF WELL/PUMP: NEIN WELL 7 WELL REPLACEMENT {1 DESTRUCTION -1 Out of Service Well C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER C Monitoring Well I❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO, PROP, LINE <br /> ATiON AGRICULTURE WELL OTHER WILL PITS/SUMPS -_ <br /> INTENDED USE TYPE OF WELD-� M AREA CONSTRUCTION SPECIFICATIONS <br /> C industrial ❑ Open Bottom ❑ Manteca of aeon Oia. of Weil Casing <br /> Cl Domestio/Prwate G Gravel Pack 7 Tracy ype of _ Specifications Q <br /> I"1 Public a Other /''�i Depth of Grout Seal TYD � 071 <br /> 1 i litigation _._ 5 <br /> Apprax_ fi l i Eastefn Surface Seal Inst:,lied by <br /> Repair Work Done Ll Tyne ump H.P. __ State Work Done— \ <br /> Well Destruction ❑ e Diameter See ling Materiall Depth 111111 <br /> Depth Filler Material 5 Depth J jJl s} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION XREPAIR/ADDITION I i DESTRUCTION I I (No septic is <br /> availabI4EWVfRaisQp9}g AL HEALTH DIVISION <br /> Installation will serve: Residence� Commercial other <br /> Numbar of Gvinq units: Number of bedrooms <br /> Character of soil to a depth of 3 teat: Water table depth �. <br /> SEPTIC TANK >r, Type/Mfg g� � L— Cap:cityNo. Compartments <br /> PKG, TREATMENT PLT.0 Tc`�j l%C LA�4J-Q,,, Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina70 <br /> \ <br /> ' LEACHING LINE '>i� No. & Length of lines ��� C���S Total length/size LQ 70 <br /> FILTER BED L7 Distance to nearest: ell `�/���77 Fountiabon Property Line <br /> SEEPAGE PITS Depth S...��_X Number _ -3 - <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance;. Siete laws, and <br /> rules and regulations 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 foe which this permit is issued,1"11 not I <br /> employ any person in such manner as to become s pct to wo(kman's compensation Iowa of Gahtnrnii.-Contractor's hiring dr subcontracting signature <br /> certifies allowing:-I carin ti'fe Porto- <br /> orto n e of the work for which this permit is)ssuod,I shall employ petsons subject to workman's compensa- <br /> tion ws O in, <br /> Tfl applicant st cal! r requir _ plate drawing/o/nr..e_ver side. <br /> Sign J Title: W it G-�«L Date.- <br /> FOR <br /> ate-FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Dote!(G Area <br /> Pit or Grout InspeCtion by Date Final Inspection b Date J2^ <br /> Additional Comments: <br /> Arpl_tcant - Return all copies to: San Joaquin County Public Health Services <br /> 1 Environmental Health Permit/Services <br /> �LFN <br /> { 445 N San Joaquin, P O Box 2009, Stkn, C 95201D iCt!'1 j <br /> AMOUR+T'Dl1E AMOUNT REMiTT Eo CK H RECEIVED BY DATE �['L/EN 1324 rAEV.iin�) (,}.t� yat <br /> Eft 14.2e __II <br />