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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> ENVIRONMENTAL HEALTH DIVISO <br /> 445 N SAN JOAQUIN, PHONE (209) 6$;�4�0 C� <br /> P 0 BOX 2009, STOCKTON, CA �} {F _ <br /> PERMIT EXPIRES 1 YEAR FROM DATE FWA <br /> (Complete in Triplicate) 7 O1 <br /> Application ie hereby made to San Joaquin Count for �� # Q/ <br /> FP Y q y permit to construct an ins t <br /> application is made In compliance vith San Joaquin County Ordinance No. 549 and 1 2 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 'n/ �j� fin/ f <br /> Job Address 1 �P• �l t r�{ v!'�t Kqto, ��� City �G� Lot Size/Acreage 1 e Z� ����� <br /> Owner's Name T rf�r`�l ��t Address ✓ 1411 "Vel. k'ZIf X Phone /q(/7 <br /> Contractor�?,"-/? Address l ,l [Ll `� ` „ <br /> License No.���� 5 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTINK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUC IFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing <br /> (l Domestic/Private ❑ Gravel Pack ❑ T Type o1 Casin Specifications <br /> 11 Public (a Other n Delta Depth of Grout Seal Type of Grout , <br /> I I Irrigation _Ap Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done U T of Pump H.P. Stats Work ne_ <br /> Well Destruction O ell Diameter Sealing Material Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> �/ available within 200 feet.) <br /> Installation will serve: Residence _ Commercial_ Other <br /> Number of living units: _Z_ Number of bedrr-ooms <br /> Character of soil to a depth of 3 feet: r ��n Water table depth <br /> SEPTIC TANK �9_ Type/Mfg OMOIiieL, Z f�e—” Capacity No. Compartments - ^� <br /> PKG. TREATMENT PLT. ❑ _ r Method of Disposal v <br /> Distance to nearest: Well_45�� Foundation Property Line AS <br /> LEACHING LINE X, No.A Length of lines l (110, i'LP Total length/size �3 <br /> FILTER BED ❑ Distance to nearest: Well 4;01 Foundation _ Property line <br /> SEEPAGE PITS 11 Depth <br /> Size_�___1S_�` Number_ <br /> SUMPS >c—, Distance to nearest: Well`l0 �- Foundation 7�l 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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies t foltowing:" 1 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such man to become sub t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t wing: "I can that in he performs e f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion Is of Call or <br /> The! licant in st all f requir ins m eta drawing on r verse 'do. <br /> Sig bad Title: Lf A. sate: r� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area <br /> Pit or Grout InspectioAb Date nal Inspection by DateAdditional Comments <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services C <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE <br /> INFO AM/OUNT DUE AMOUNT REMITTED ,(CASH �7 RECEIVED BY DATE PERMIT NO. <br /> EH 11-24(REV,tinct <br /> EH 14-2e V/ y - . Il " s I " �� ` 1 Iq A-3 � <br />