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APPLICATION _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVA& <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,PHONE(209)469-34 - <br /> P O BOX 388,STOCKTON,CA 95201-03 3 3 <br /> PERMIT EXPIRES 1 YEAR FR D <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri d.�This#pplication is made in compliance <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115..3 and the Rules and Regulations of Sank2jkuin 4 b'c eal Se ces. <br /> / 13.,�. Al , t4 1191 N �j , City S Lo 1L creage <br /> Job Address (/ <br /> Owner's Name L. M �� ��` Address <br /> an/ QQL,, �yJ <br /> Contracts <br /> Address // ,'`Q� License No. a2 Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Out of Service Wel O <br /> PUMP INSTALLATION G SYSTEM REPAIR O OTHER G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial O Open Bottom ❑ Manteca Die. of Well Excavationit <br /> Dia. of Well Casing <br /> [I Domestic/Private L1Gravel Pack ❑ Tracy Type of Casing__ 5T0 -2 c <br /> I1 Public Cl Other n Delta Depth of Grout Seal Type <br /> i I Imgatron —Approx. Depth I I Eastern Surface Seal Installed by �/fO <br /> Repair Work Done U Type of Pump H.P. _— State Work Done_ <br /> /r <br /> Well Destruction � Sealing Materiel i Depth <br /> Well Diameter <br /> Depth �0 7 -/ Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic <br /> system permitted it public sewer it <br /> dbvhm� ' ` <br /> Installation will serve: Residence_ Commercial_ Other Z <br /> Number of living units: Number of bedrooms ENT <br /> Character of soil to a depth of 3 feet: Water table de <br /> SEPTIC TANK O Type/Mfg Capacity No. Compann'" <br /> PKG. TREATMENT PLT. O Method of D*j <br /> Distance to nearest: Well Foundation Property Line JJ <br /> ceN 10AQU <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> LIC HEAPuR <br /> I�;QN <br /> FILTER BED Cl Distance to nearest: Well Founaatron Property Lin,j NVIRON <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance o1 the work for which this peanut is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compenss- <br /> tion laws of California." <br /> The applicant at call for all required inspections. Complete drawing on reverseside. / <br /> Signed %� — f�lTitle: a &e ix Date: <br /> FOR PART NT USE ONLY <br /> Application Accepted by Date 6 res �Z <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant, - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N.San Joaquin.P.O.Box 388,Stockton,CA 95201-0388 <br /> ` FEE AMOUNT DUE AMOUNT REMITTED K M RECEIVED BY DATE PERMIT NO. <br /> INFO ///��� <br /> (((��� <br /> to 13�1 <br /> _ <br /> . EM 13-24 i11E1/.rieDr � O+ O•tJV d <br /> EM 14-y <br />