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r <br /> I APPLICATION. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE9t . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> " x,445 N SAN JOAQUIN, PHONE (209)468-3420 JUN 11 1992 <br /> P 0 BOX 2009, STOCKTON, CA 95201illI€ OifJlNTL HEALTH <br /> ''PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pERM117SERVICES <br /> �4yn � �% p '�COlfl]s�ete gill sT} 1pJ C`dtB-)vr� y •fir <br /> ,. , <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 Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Healtha vice <br /> Job Address uv`"`'t City Lot Size/Acreage <br /> rOwner's Name K,1 1✓ Address,��J Phone, <br /> /DLr v�it v+/it+ty � /1rI �,//J�,/J- <br /> ntrattor rens �/�� '�(:[� ~`License No. Phone 24 ' <br /> TYPE OF WELL/PUMP:- NEW ❑ WELL REPLACE -tNT Ei DESTRUCTION 0 Out of. Service Well C1 <br /> j <br /> PUMP INSTALLATION SY57EM'-REPAIR,_C1 OTHER C3 monitoring NellG7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLr 0 <br /> THER-NVEL1 PITS/SUMPS <br /> f' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41 <br /> ❑ Industrial 4 ❑-Open Bottom ❑ Manteca Dia. of•Well,Excavation Dia. of Well Casing <br /> &H�rb—mestic/Private Cl Gravel Pack ''" 7 Tracy Type of Casing_' Specifications <br /> I') Public 1-1 Other ! Fl=Delt3 Depth of Grout Seal Type at Grout <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> n; <br /> Repair Work Done U Type of Pump �-� H.P. Z/ State Work Done <br /> Well Destruction ❑ Well Diameter~ko Sealing.-liaterial-& Bepth <br /> '' <br /> rKr Filler Material & Depth gf <br /> Depth I���� k p -C-- - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATtOWI'I REPAIRlADDITION 1-1--DESTRUCTION I I.INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Z Commercial'� Other <br /> 1 , .. ..,� W t r th <br /> -'. Number of living units: Nurriberbe <br /> pof drooms -- - .. <br /> r f � <br /> Character of sail to a depth of 3 feet:f a e table bep 1 { <br /> SEPTIC TANK ❑ Typa/MfgNo. Comparfinent's <br /> PKG. TREATMENT.PLT. Q. <br /> hAeihod of Dispose! <br /> Distance to nearest:-, Well 'Foundation - Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearesi WellFoundation 1 Property Line � <br /> SEEPAGE PITS I I Depth t —Size Number <br /> SUMPS Ll Distance to nearest: Welt Foundation Property Line 1 <br /> DISPOSAL PONDS ❑ 4 <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 sub-contracting signature <br /> certifies the following: "I certify 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." i <br /> The applica rt Cal uired inspections. Complete drawing on rev r side. i <br /> Sig Title: Date., �d <br /> :F D ART <br /> MENT:USE-GNL-YL�-_ <br /> r r <br /> Application Accepted by Date fee <br /> Pit or Grout Inspection by . Date Final Inspection by Data <br /> t i <br /> Additional Comments: t <br /> I <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> Environmental Health permit/Services <br /> E 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IF FO AMOUNT DUE AMOUNT REMITTED) CK CAJH <br /> CEIVED Y DA PERMIT'NO. <br />� r <br /> . EN 13-24(REV. /n5) ,) -r- <br /> EH 11.211 LT O� <br />