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APPLICATION <br /> t SAN *QUIN COUNTY PUBLIC HEALTH &VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San "o q �Co}mP a e f7p105L,4,�1$62 and the Rules and Regulations of San <br /> Joaquin County PublicHealth Ser vlc�e�e,.�y J- f;qv y/�- ) �/J��(/�1/ �],/�/� <br /> Job Addres,kO— N• r+�.(YU(.r9 -A-3r/n�e-...r•y.Lr3�.4717 '/�i /��A Cit�Q / Lot Siz/e/Acreage /J/G(y_, <br /> Owner's Name <br /> n�,�-�c-,/� d�c ��?16CV Address Pr{/E/,/,��1� ice / 93y 7�/�n�,c Phone <br /> Convector CliflN/7'1 GiG C.ac/�/I.flddreJs/s `S' N�V csc No.v�.},�",/ Pnone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX Monitoring Well O <br /> SA;jJ:f E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 6�X 1;5-h `n­'�,- <br /> ❑ Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. StateVt(01 Dgne _ <br /> Weil Destruction ❑ Well Diameter Sealing Material L Depth O c:.. Grit <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 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: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ o ispo321 <br /> Distance to nearest: Well Foundation Pro)ine <br /> 11061992 <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> ENVIRO <br /> NIeq7 HEALTH <br /> SEEPAGE PITS 1 1 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, and <br /> 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "1 ce ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appliciii01, <br /> ll mqui a inspe tions. Complete drawing on r se side. �— <br /> Signed X Title Date: <br /> ZLFORIEPARTMENT USE ONLY <br /> .' Application Accepted by `' Date ��,t I- Area •J v 1 <br /> Pit or Grout Inspection by Date Final Inspection by /v��7�- V''t% Data <br /> Additional Comments: n <br /> Applicant - Return all copies to: San Joaquin County Public Health Services •1 �q� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE <br /> INFO AM�OUNNT DUE AMOUNT REMITTED CCAKSL, RECEIVED BY DATE <br /> R^ PERMIT1'NO. <br /> EH Ib 24 IREV.Ir•!1 C� /� I -��� $ �� �j" l V I ,I� <br /> EH tx 28 L <br />