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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH iu - <br /> 445 <br /> V3�A <br /> ENVIRONIMTAL HEALTH DIVISIt[� <br /> N SAN JOAQUIN, PHONE (209)46 &# <br /> P 0 BOX 2009, STOC%TON, CA 952)1-AC <br /> EXPIRES DATE FF LL,, 0�7 <br /> (Complete in Triplicate) tt • LL <br /> Application is hereby made.to San-Joaquin County for a permit to construct and/or install the vork herein described. This <br /> appllcatlon is suds in cottpliaace vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> n/ Public <br /> `Health services. � }QQ `` <br /> Job Address d.���� i 'S 1+ \.y�{��SLt ' 1� Cr CitAollki ` Lot Size/Acreage aG <br /> Owner el!lame _ X1'1��\ <br /> Phone <br /> 7 <br /> Contiettt C, , r W Address t `�GX���� ( 1\� + License N.5_2 0 1 �'' Phone�0 — �dJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n. DESTRUCTION Cl-Out-of Service Mall <br /> - PUMP-INSTALLATION ❑" SYSTEM REPAIR CT -- OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI <br /> 1 i <br /> C71 Industrial ❑ Open Bottom ❑ Manteca Du. of Well Excavation Kitt W V6D Well Casing <br /> N Domestic/Private Cl Gr" Pack ❑ Tracy Type of`Casinpl�- hill Ah ��JJTtticatioru <br /> I'I Public 171 Other n Delta Depth of Grout Seal4 Clypt,pj rout <br /> I I Irrigation <br /> J UUUUUUUUNNNNNTT . <br /> Appros, Depth I 1 Eastern SuAaca Senl lnsutlod.b <br /> Repair Work Done U Type of Pump H.P. - r <br /> Well Destruction ❑ Well Diameter Sealing Material Z Depth. <br /> Depth 7111er Nauriil_A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/'ADDITION' +DESTRUC710N 1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will tarty: Residence Commercial Other <br /> Number of W units: . f Wing �: Number of bedr s J ' <br /> Character of"a to a depth of 3 flet:/ �. �^� Wailer table depth <br /> SEPTIC TANK ❑-i Type%fiAfg'`" Capachy :Nod ompartmenb <br /> PKG.TREATMENT PLT.❑ t� � v <br /> -Method of Disposal— <br /> Distance to nearest'.` - Wea— — .Foundation 'Prol!" Line <br /> — <br /> LEACHING UNE No. 8 Length of lines• _-�� -yCN �7otal length/sus K <br /> ' -- - <br /> FILTER 9ED T ❑ Distance to nearest: Wall 150- r Foundation - Property Lina <br /> SEEPAGE PITSDepth Size _�(V Number <br /> SUMPS LI Distance to nearest: Will 100, Foundation 0 t 4' Property Line—,�4-, <br /> DISPOSAL PONDS ❑ <br /> 1 heriby 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 Sen Joaquin County <br /> Homeowner a 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 eub-contracting signature <br /> mortifies the following: "I certify that in the perforrt►arncs of the work for which this permit is issued,1 shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for it mepections. Complete drawing on;14rsa side. -'"�" ' max' •-� ` !� - Q <br /> Signed ` l Title: • k + <br /> Date: <br /> FOR DEPARTMENT USE ONLY 0 <br /> AAp Jplication Accepted by Dais II <br /> �R/Of Grout Inspection byr Date Final Inspection b <br /> Addttlonal Comments: <br /> + <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Eovironoental Health Permit/3e.rvicea <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ` FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 0 TE PERMIT'H0. <br /> 1 INFO <br /> . Ex 13 24 tREV.+ R e+ 1 <br /> EM 14•38 L . <br /> i <br />