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Lot Size/Acreage s t- <br /> <br />Phone <br />Date. <br />San Joriguin County Public Health Services <br />Enviroental Health Permit/Services <br />445 N San Jos. <br />1 <br /> Box 2009, Stkn, CA 95201 <br />01, ---......1. <br />to: <br />PERMIT' NO. DATE RECEIVED BY <br />Additional Comments: ID k 12-01\ <br />Applicant - Return all copies <br />£14 13-24 M(V. 11115) <br />EH 14-211 74 <br />AMOUNT DUE AMOUNT REMITTED FEE <br />INFO m47 <br />91-4.5/3- etv.xac/ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR PERMIT <br />w! imclo <br />Bci <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 hertin described. This <br />application is made in ccapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Palle Health Send s. <br />t7c <br />License No. /L.23/Phone 9Y/Z-5.9'9 <br />WELL REPLACEMENT DESTRUCTION 0 Out of Service Well 0 <br />SYSTEM REPAIR 0 <br />OTHER o Monitoring Well 0 <br /> SEWER LINES DISPOSAL FLD PROP. LINE <br />AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Manteca Die. of Well Excavation Dia. of Well Casing <br />Tracy Type of Casing_ Specifications <br />Delta Depth of Grout Seal Type of Grout <br />I 1 Eastern Surface Seal Installed by <br />H.P. State Work Done <br />Sealing Material 4 Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION IC...REPAIR/ADDITION DESTRUCTION 1 I (No septic system permitted if public sewer 4 <br />available within 200 feet.) <br />Installation will serve: Resiflence / Commercial ____ Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br /> Capacity <br />PKG. TREATMENT PLT. 0 <br />Distance ,to nearest: <br />LEACHING LINE Cl No. 6 Length of lines Total length/size <br />FILTER BED 0 Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS 1 L Depth 3.' Size I Number <br />_§,yn_,m )4' Distance to nearest: Well Foundation Property Line <br />DlSPOSAL PONDS 0 <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 regulatidns of the San Joaquin County Horne owner or licerssid 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 workmen's compensation laws of California.- Contractor's hiring or sub-contracting signature <br />certifies the following: "'l certify that in the perfbrmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />lions. Compl <br />-17 k-et <br />Application Accepted by <br />Ph or Grout Inspection by Date <br />Job Address <br />Owner's Name <br />Contractor <br />TYPE OF WELL/ <br />Address <br />NEW WELL 0 <br />PUMP INSTALLATION 0 <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION <br />UMP: <br />Address <br />INTENDED USE <br />0 Industrial <br />CI Domestic/ Private <br />1'1 Public <br />iihriotion <br />Repeir Work Done <br />Well Destruction <br />TYPE OF WELL <br />0 Open Bottom <br />0 Gravel Pack <br />Other <br />Approx, Depth <br />Type of Pump <br />Well Diameter <br />Depth tiller-Material th <br />SEPTIC TANK 0 Type/Mfg No. Compartments <br />Method of Disposal <br />Well Foundation Property Line <br />The applicant for <br />Signed X <br />drawing oeverse side. <br />Title: OW <br />FOR DEPARTMENT USE ONLY <br /> Date <br />Final Inspection b