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)%001 APPLICATION <br /> SAN JOAQUM COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 1 <br /> PERMIT =TRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin Cot:ty 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 and Regulations of San <br /> Joaquin County Public Health Services. I _ <br /> Jon Address Cj� 4a�vi ii'n C r- L—t vat' C.:v C.� 1'I Lot Size/Acreage '`s­ V"L ctC rr_ <br /> II i <br /> Owners Name E 'n,lJ4n U�_ address 2-3`00 e uta �La� (LS L% Phone (�fG LL/6-S <br /> Bo Xyi,?l <br /> IfI ( <br /> Contractor lsctl�to4�✓r�tit XVV4i ( Apdress?(, " CY1tciLit��>4SIc _cense No. e � J~E7I g1 P�one��ef S'2�72L <br /> TYPE OF WELL/PUMP! NEW WELL = .YELL REPLACEMENT .- DESTRUCTION 7 Out of Service Well Z j <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. '-INE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1"' <br /> ndusvia C Open Bottom C Manteca Dia. of Well Excavation �o" Dia. of Well Casing �' <br /> Domestic/Private C Graves Pack Tracy Type of Casing_ 1!L Specifications h <br /> Public !-I Other iii Data Depth of Grout Seal �O Type of Grout dirwa ICN 1-arj�G <br /> Irrigation Approx. Depth i Eastern Surface Seat Instailao by i <br /> Repair Work Done u Type of Pump F. _ State Work Done _ <br /> Wee Destruction Well Diameter ceallr.g l4aLerial 6 Depth <br /> Deatn Ftiler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION - :iEPAIR:AOOIT!ON : DESTRUCTION i lNo septic system oermnted it public sewer is <br /> avaiubis within 200 feet.l <br /> Installation will serve: Residence_ Commercta_ :her <br /> i <br /> Number of living units: _ Number of badrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ rvpe/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C Method of Disposal <br /> C.stance to nearest: Nee Foundation Property Line <br /> LEACHING LINE C7 No. 8 Length of lines Total lengtn/size , <br /> FILTER BED M Distance to nearest: :yell Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS LI Distance to nearest: :veil Foundation Property Lina <br /> DISPOSAL PONOS C <br /> I hereoy certify that I have prepared this application aro trial the work wul be done in accordance wish San Joaquin county ordinances. stats taws. and <br /> rubs and regulations at the San Joaquin County <br /> Home owner or licensed agent's signature certifies ins foaowrng: 'I certify that in the performance of the work for which this perrnrt is issued. I shall not <br /> employ any person in such manner as to become subtest to woMman s compensation laws or Caulomia. Contractor's hiring or 3uo-contracting signature <br /> certifies the following: "I csrtly tnat in the performance of ins work for which this permit 6 issued. I shall employ persons subject to workman"s comoonsa- <br /> cion laws of California." <br /> The applicant must call for all required inspections. Coraaete drawing on reverse stag./' j C <br /> Signed X = - Title: Oats: <br /> �11 � d. ` <br /> Appucanon Accepted by FOR DEPARTMENT USE ONLY Date � /� C�,lin At" `�� p 603 <br /> Pit or Grout Inspection by �'' -� Date ��/L r C/ °insl Inspection by r`�• ^^"'"-� Date (ll `��� <br /> Additional Comments: J, <br /> Appliesant - Return all copies to: San .;oaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 ti San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE I AMOUNT?EMITTED :aSH RECEIVED By ( DATE PERMIT NO. I <br /> NFO - -- ^ Pa <br /> ge 13.4 <br />