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APPLICATION v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQIIIN, PHONE (209)46$-3420 <br /> i P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> f PERMIT EXPIRES_1__yEAR_1__yFROM DATE -MUMD <br /> It (Complete in Triplicate) <br /> A licetion is hereby made to Safi o Joaquin County for a permit to construct and/or instL9 and 1862 al, <br /> c" eeRules andt� <br /> Aeatiowork hein nadof Sans <br /> pp <br /> application is made in conpliance with San Joaquin County Ordinance <br /> Joaquin county Public Health services. <br /> Cgi <br /> I/ . t h Cif <br /> Lot Size/Acreage <br /> 6U CirerR <br /> a <br /> Job Address � <br /> � �/qS,'� Phone <br /> I Owner's Name �M� tis` Address <br /> Address �f/ <br /> ` �D��jj?C 3��av License No. Phone f`-J5 <br /> Contractor -� <br /> TYPE Of WELLlPUMP; NEW WELL C3 WELL REPLACEMENT C1 DESTRUCTION LD of Service We31 O <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER G, Monitoring Well O <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> G Manteca Dia-of-Well-Excavation--- ----- »Dia. of Well Casing <br /> C] industrial O Open Bottom <br /> Type of Casing_ Specifications <br /> t ;' Domestic/Private ❑ Gravel Pack ❑ Tracy Y <br /> I'I Public of Grout <br /> Cl Other n Delta Depth of Grout Seal Type' <br /> j \i i Irrigation — Approx. Depth I I Eastern Surface Seal Installed tW <br /> Repair Worst Done U Type of Pump H.P. State Work Done_ <br /> Sealing Material i Depth <br /> Well Destruction C) Well Diane`r • <br /> Depth Filler Hater el & Depth <br /> TYPE Of SEPTIC WORK: NEW IN TA LATION I I REPAIRIADDITION I ' DESTRUCTION I i (No septic.system permitted if public sewer,is <br /> I. available within 200 feet.) <br /> Installation will serve: Resi encs Commercial— OjherT 1� .f <br /> Number of livingunits: Number of bedrooms ,--—V"' '- <br /> r '� Watsf tabla depth <br /> Character of and to a depth of 3 feet: <br /> SEPTIC TANK Type/Mfg pacity No. Compartments \, <br /> C PKG. TREATMENT PLT.❑ of Disposal (�\l <br /> Distance to nearest: Well Foundation" J Property Line <br /> tit LEACHING LINE i No. & Length of lines Total length/size <br /> k FILTER BED CJ Distance to nearest: Well�ZFoundation _ /b r_ Property Line Ay J- <br /> 12 <br /> FILTER <br /> PITS I I Depth Size n 0 Number <br /> y O ' _Pro Line I, l <br /> SUMPS Distance to nearest: Nlell -� <br /> 2—Foundation � <br /> pe!LY_ _ +[5�- - <br /> DISPOSAL PONDS ❑ ' --' �' <br /> 1 hereby certify that I have prepired this application ands at'the work will be done in accor8ance.with San Joaquin county ordinances, state laws,and <br /> rules and regulations of the San Joaquin County <br /> f Home owner or licensed agint's signature certifies the following: "I certify that in the-periormance 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 /> t certifies the fopowing: 1.1 unity that in the performance of the work for which this permit is issued,%shall employ jpwsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all r fired i spgctions , Comptate'drevving on reverse side.��'�+_ <br /> Title: J° Date: <br /> 3 <br /> Signed <br /> E FOR DEPARTMENT USE ONLY Z <br /> Applictbn Accepted by Date Area <br /> a <br /> Pit or Grout Inspection by Date .Final Inspection by Date <br /> Additional Comments; <br /> ' App2lcant- ke£urti`ail'copiea to"'Sao Joaquin'County P1ib1iC Health Service's <br /> Environmental Health Permit/Services <br /> j 445 N San Joaquin.,, P O Box,2009, Stkn, CA_95201 <br /> FEP OUNT Dt1E AMOUNT REMITTED CASHRECEIVED BY DATE- ` PERMIT'NO. <br /> INFEM 1344IREV.I/A5i Zq 3-(. <br /> EM 14-2a <br />