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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION R' <br /> 4 445 N SAN JOAQUIN, PHONE <br /> E <br /> P O BOX 2009, STOCgTON <br /> 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />�. (Complete in Triplicate) <br /> the work herein described. This <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install <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. ` d7 D C <br /> cityLot Size�reage aC <br /> )(Job Address ; ��6 <br /> JM3 <br /> I ���� PhonAddress er�� 4 �x Owner's Name �i� V f - � 77 <br /> L . ./ Address' <br /> .76'"i�(lC.�I�� -- License No � rho <br /> 5�COnttacto _ DESTRUCTION-❑'O+rt of Service Well G1 <br /> TYPE Of ELL/PUMP: NEW WELL WELL REPLACEM1i1ElJT n monitoring Well L; <br /> �/ SYSTEM REPAIR L� OTHER ❑ <br /> PUMP INSTALLATION lid ���+ 5� ,& POOP. LINE <br /> �D ='�. 9T SEWER-LINES ,' <br /> DISTANCE TO NEAREST: SEPTIC TANK '~� OTHER WELLQ— P€T5ISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE —•----- Dia. of well Casing <br /> C1 Open Bottom ❑ Manteca Dia, of Well Excavation �i�D f <br /> {7 Industrial �/� '� (� 5pecilications. }, <br /> Type of Casing r ,�-. <br /> I C:1 <br /> Domestic/Private I (Gravel Pack ❑ Tracy Type of Grout s <br /> i'1 Priblic 4 , <br /> €1 Other l l Delta Depth of Grout Seal � 6 <br /> keirrigation Appr`ox. Depth I I Eastern Surface Seal Installed by p <br /> H P '� States Work -----�� <br /> Repair Work Done EJ Type of Pump Sealing material 8 Depth <br /> r k*, P <br /> Well Destruction ❑ Well Diameter Filler materiel i Depth <br /> Depth , <br /> YPE OF SEPTIC WORK: NEW INSTALLATION I I REPA1plADDITION.{ I DESTRUCTION I 1 available.ble.wthin 200-feet.)c §Ystsm red if public sewer is <br /> 'tet' r <br /> Installation will serve: Residence Commerc Other € € <br /> Number of living units: Number of bedrooms °, � *A <br /> _ - -� --� -Water la 10 depth. ---- <br /> Character of soil to a depth of 3 feet: ` No. Campartment9!­� <br /> f SEPTIC TANK r0 Type/Mfg Capacity <br /> Method of Disposal <br /> Pkv. TREATMENT PLT. ❑ <br /> Distance to nearest: Wel <br /> Foundation Property Line <br /> Ff' , <br /> '. Total length/size <br /> ` LEACHING LINE C1 No. & Length of Iii s property Line <br /> 1 FILTER BED ❑ Distance to n rest:, Well undation ��� � r <br /> 'Number '_ t <br /> SEEPAGE PITS ,C ;�_, 1 1 Depth Size i .n <br /> ,. <br /> SUMPS Ll Distance to nearest: WellFoundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, states, and <br /> 4 rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies 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,Harmer as to become subject to'workman's compensation laws of California." Contractor's hiring or-suG contracting signature <br /> certifies the following: ' certify the a performance of the work for which this permit is issued, 1 shall employ persons subjec to workman's compensa , <br /> tion laws of C la," I r <br /> 'The applica t for a ns. Complete drawing on reverse`side. T <br /> Title: 11�"'" Date: 4 <br /> Signed ? <br /> FO DEPARTMENT U E O LY <br /> Dati 1'30 Z Area <br /> Application Accepted by } <br /> Dat Inst Inspection by Date%� <br /> Pit or t2royt Inspection by �, '7 _ _ r J. _.,,7 <br /> Additional Comments: <br /> Applicant - fReturn all copies to; San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stkh, CA 95201 <br /> a <br /> FEE CK ECEIVED By ATE PERMIT NO. <br /> AMOUNT DUE AMOUNT EMITTED H <br /> INFO � � 15irJ y <br /> W <br /> . EM 132 iREV.I/ <br />