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AN. JOAy�UIN_-.COST`-'--rP <br /> V I RONMF.NTAT. HEALTH DIVISION <br />• t 445 N SAt+i SOAQUIN; PHONE (209)469=34-20 <br />` p O BOX 2009, ST06KTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f permit to construct an <br /> install the work herein described. This <br /> Application is hereby made,to San Joaquin County for a pe <br /> and 1862 and the.Rules and Regulations of San , <br /> application is made in coupliance with Ban Joaquin County Ordinance No. 549 <br /> Joaquin County Public Health Services. <br /> �! .� Lot Size/Acreage <br /> S City J6�y�/ /� ' <br /> Job Address .�7 S O <br /> 1. Phone 7� <br /> t CSI Address . <br /> Owner's dame <br /> � '' "�,�5 Phone y <br /> Address o License No�77�" <br /> contractor t^ QESTRUCTION ❑ Out of Service Well ❑ <br /> NEW WELL �yG WELL REPLACEMENT C..] Monitoring Well. �� <br /> TYPE OF WELL/PUMP: r SYSTEM REPAIR ❑ OTHER ❑ r y <br /> PUMP INSTALLATION DISPOSAL FLD. PROP. LINE <br /> SEWER LINES -- PITS/SUMPS <br /> DISTANCE I NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL, --� <br /> FOUNDATION �� <br /> INTENDED USE f TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> M Iridustrial ❑ Open Bottom ❑ Manteca-. Dia. of Well Excavation Specifications <br /> I i ❑ Tracy Type of Casing_— -�� !ti <br /> % ]cpomestic/Private + Graves Pack r Type al Grout � <br /> (.l Other Fl Delta Depth of Grout Seak-�'� <br /> ['].Public P D dace Seal�ln is alled by <br /> I ] Irrigation L� Approx. Depth III Eastern State Work Done f <br /> Repair Work Done 0 Type!of Pump �— H P r <br /> Sealing Material & Depth <br /> Well Destruction �1, Well Diameter Filler Material & Depth <br /> `Depth .•. <br /> rmitted it ublic stlwe <br /> INo r is <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRlADOITION I 1 DESTRUCTION [ I septic system pe <br /> 1EI Installation will serve: Residence 0=. Commercial_ Other <br /> Number of living units: Number of bedrooms — Water table depth <br /> Character of soil to It depth of 3 feet: < i ' Capacity�.. No. Compartments <br /> r SEPTIC TANK, a 0 Type/rMfg-- t -Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ��s}, <br /> : Foundation Property Line <br /> Distance to to nearest:- Welles' _ <br /> P <br /> Total length/size <br /> LEACHING LINE ❑. No. & Length at lines Foundation Property Line <br /> FILTER BED f=] =mDistance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS I I Depth — Property Line <br /> LI Distance to nearest: Well'----7— <br /> DISPOSAL <br /> ell' Foundation —- <br /> - SUMPS � <br /> e DISPOSAL PONDS ❑ <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 • "I certify that in the performance of the work for which this permit is issue . Isihnlaturel not� <br /> I Home owner or licensed agent's signature certifies the following. Y <br /> employ any person in such manner as to become subject to workman's compensation laws of California."a lContractor's hiring or sub-contractingwork <br /> canities the following:"1 certify that in the performance of the work for which this permit is issued, t shall employ parsons subject to workman's compansa <br /> tion laws of California."" <br /> The applicant must call for I required inspeptions. Complete drawing on reverse side. <br /> Title: X Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY ,� �f � l� _ <br /> Data Area <br /> Application Accepted bA- <br /> �ou <br /> Date --- <br /> -Oate Final Inspection by <br /> Pit spection <br /> Additional Comments: --6 <br /> Applicant - Return all copies to: EnoPublicall Joaquin COuntY <br /> Environmental Health vealth ices <br /> /Services <br /> 445 N San Joaquin, p O Box 2009, StXn, CA 95201 <br /> i CK RECEIVED BY DATE P RMIT'NO. <br /> k FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INF <br /> t . t;H13.241REV.IJx51 1� r � ' <br />