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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' (Complete in Triplicate) <br /> Application in hereby mede.to Ban Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in co®pliance with Ilan Joaquin County Ordinance No. 149 and 1962 and the Ru lea and Regulations of San <br /> ' Joaquin County Public Health Services. <br /> A-P.J #'- °Ila-3ao- to <br /> Job Address Cit Lot Size/Acreage AL <br /> '{Op 5062 J 7°L'l��i scllTk-.3r?1 <br /> Owner's Name Address ;1 y6f112.r Phon� <br /> Conlractor L ddress ✓ �" l l nee No 52P�6rYev � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring/Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES N '7 DISPOSAL FLO.,-4 A PROP. LINE'�� <br /> FOUNDATION f AGRICULTURE WELL -d24- OTHER WELL'"-r2n- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PF108LEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing —tYJ A ✓{'1 Specilications .2.5AJ, :�d —� <br /> ' 1'I P,rblic 1:1 Other fl Delta Depth of Grout Seal 't"/� r Type of Grout <br /> 1 1 Irrigation ,312 Approx. Depth I I Eastern Surface Soul Installed b <br /> Repair Work Done U Type of Pump H.P. Stafa Work Pone_ <br /> ' Wali Destruction ❑ Well Diameter r�r! Sealing - <br /> i Depth / <br /> Depth (} r Filler Haterial i Depth 1141 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 (eet.) <br /> Installation will terve: Residence— Commercial„__._ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK f3 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> y <br /> LEACHING LINE ❑ No. 3 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation . Property Line <br /> ' SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance 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 subcontracting signature <br /> ' certil€es the following: "I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compenttia- <br /> tion laws of California." <br /> The applicant mu all for all re uirgd Inspectl ns. Complete drawing on re ver a side. <br /> Signed Title: Date: <br /> ' <br /> EPA M1' <br /> ON Y <br /> Application Accept by Rata Area <br /> ' Pit or Grout Inspection by Date Final Inspection by Date <br /> . Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health Services <br /> ' Environmental Health Permit/Services <br /> t 4435 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> ' Ex 17-24 IRE .rrner eU "lion <br /> G ��lJ <br /> EH 1LI0 <br />