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,AT &LSD ,/- t/— cam----- r r c C!J <br /> K�,��� � Ears 1-► APPLICATION uu <br /> /0 lcw6edtt- -`f - SAN JOAQUIN COUNTY PUBLIC HEALTH SISRI <br /> _ l)�o � / ENV I RONMENTAL HEALTH DI V I S %� bi <br /> c�,d wr�uc wed 445 N SAN JOAQUIN, PHONE (209)46% <br /> �--- <br /> P O BOX 2009, STOCKTON, CA 9 2i0� <br /> PERM T ESPI YEAR FROM DATE MMM <br /> (Complete in Triplicate) ' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or inste]1 the work herein described. This <br /> application is Lade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> t 1 _ <br /> Job Address ,) City� C Lot Size/Acreage <br /> Owner's Name e Address Phone <br /> r Q <br /> Conttaclor ,Address [ / ,/� �4r.�(S _ License No. Phone 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Wall ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIR O OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial D Open Bottom Ci Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> F.] Domestic/Private O Gravel Pack ❑ Tracy Type of Casi(N_ Specifications <br /> I'1 Pubwc fa Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I lrfvjation _Approx. Depth I I Eastem Surface Seat Instrlled by t+� <br /> Repair Work Done L7 Type of Pump H.P. ___ State Work Done _ v <br /> Well Destruction ❑ Wen Diameter Ses lies Material i Depth � <br /> Depth Filler Material h Depth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 last.)/ L <br /> Installation will serve: Residence _ Commercial-, Other j_ ��V� 1jl1 ��Y / J <br /> Number of living,units: Number of bedrooms I`�� ��Q lj JJf t �cot� <br /> Character of sod to a depth of 3 feet: / Weler table depth <br /> SEPTIC TANK f] Type/Mfg Capecityt `.J - No. Compartments <br /> PKG. TREATMENT PLT. ❑ 6s� Method of Disposal <br /> Distance to nearest: Well,— Foundation _ Property Line <br /> LEACHING LINE D No. b Length of . ✓�� �l �7� J )\otat length/size <br /> FILTER BED 09 Distance to nearest: Well 1-3'6— Foundation 4f_ Property Line _ <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to newest: Well Foundation ProppArty Lina <br /> DISPOSAL PONDS ❑ <br /> 1 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 regulstiora of the Sen Joaquin County <br /> Home owner or licensed agent's signature 0111121111e following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in au nnar as to subject to workman's compensation taws of California."Contractors hiring or subcontracting signature <br /> "nil-me the faMow' I fy that in ormance of the work for which this permit is issued, I shah employ persons subject to man s ss- <br /> tion laws of Cap rete." r� f�PS e�tt`/icG- <br /> The applicant aM for a!i roqui inspections- Mete drawing on reverse side. 5�D00 r <br /> Signed itle: <br /> FOR DEPARTMENT USE ONLY Q­Application Accepted by Date T Area_�- <br /> Pit or Grout Impaction by bate Final Inspection by Data <br /> Additfor►al Comments, <br /> Applicant - Return all copies to: San Joaquin County Public Health Service <br /> A <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 9 01 <br /> v�Z , INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> EH;3-24 MEV.r ■51.5 /-f�, <br /> EH 14-M ! '��� 4,-C\) <br />