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APPLICATION LAC <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> 445 N SAN JOAQUIN, PHONE(209)469-P O BOX 388,STOCKTON,CA 95201-0REUIT I 1 R(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 opplication is made in rompliance with San <br /> Joaquin County Development Title <br /> Title Sec/cl/Un/9)-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services, <br /> Job Address ,`.�_L�C_SL <br /> �11! I AO _ CityLot 51ze/Acrrsge d / <br /> Owners Name • , Address <br /> Contracto `r I ` e Address t " tLicense N / <br /> TYPE OF WELLIPUMP: N:W WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service lfsl.1 <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER O Moaitoring Well Q <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL !LD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER VALL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p�Y T <br /> n Industnel D Open Sonorn D Manteca Dia, of Wall Excavation• OS-PAX [ 1�� <br /> (.l DonesticlPrivale ❑ Gravel Pack ❑ Tracv Type of CasingARt�dMr�f <br /> i'I Publit 11 Other (l Oalu Depth of Grout Sesf TtrM ff(" - <br /> I I Irl+patron AWoit. Oepth I I Eastern Surface Saul Installed by SANJUAQ <br /> Repo.Work Done U Type of Pump N.P. State Work Done S <br /> Waif Oatffruction D Wall Diamatar Sealing Materi.l i Depth EALTH DIVISION <br /> Depth Tiller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITION I ! DESTRUCTION 1 i (No septic system permitted if public Howe is <br /> y available within ZOO tN1.1 <br /> Installation will verve: Residence* Commercisf kl": Other. /W7�� <br /> Number of kir" units; Number of boidtoome <br /> Character of loll to a depth of 3 feeWater table dgxh T1 <br /> SEPTIC TANK TyprlMfCapac ty No. Compartments <br /> PKG. TREATMENT PLY O ( / Method of Disposal <br /> IL 0 <br /> Distance to nearest: Weal! �7oundation�� --10 Property Line 37— <br /> /� <br /> LEACHING LINE No. b Length of lines To•el length/size Air <br /> FILTER BED n Distance to nearest- Wall _ Foundation _ Property Line sr <br /> l/ <br /> SEEPAGE PITS Oeplh Sire <br /> SUMPS LI Distance to retirsrt: Wall -/-1Cd- L4-foundotion /D `� Property Liar T <br /> DISPOSAL PONDS O _ <br /> 1 hereby Comity that I have prepared this application and that the work will W done in accordance with San Jo.Nquin county ordw,ances, state laws. <br /> em <br /> rules and repuleltons of the San Joagr;in County <br /> Hone owner or licensed agent's signature certifies the follow+ng: "I certify that In the performance of the work for which this permit is issued, I shall <br /> employ any person In such menw as to become subject to workman's compensation taws of Calilornia."Cont►actor►firing or sub-contracting signatur <br /> canities the foilowing: "I sanity that in the performance of the work for which this permtit is issued, I shall employ persons subject to workman's eornpen <br /> tion taws of CaAlornis." <br /> The applicant am for til ed apgetiona. CompNto dnwrng on rover"s dee <br /> Sigrid 7icle: L Data: (� <br /> FOR DEPARTMENT USE ONLY /,/� <br /> /Application Accepted by Date rL1_ Arra <br /> (0,4 Grout fr joection by `*Final Inspection by • , Gtr.� Doe Z— ]Z Q <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Envimarncatal Health Permit/Services <br /> 445 N.San Joaquin,P.O.Box 3811,Stockton,CA 95201-03 C � Q f Q <br /> ►� f FEE/ AMOUNT DUE AMOU REMITTED RECEIVED 8 J PERMIT'NO'O <br /> �JJ{ INF 1N� <br /> Elm 12.144eEv.„a sl <br />