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APPLICATION <br /> USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> '� ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P. 0 BOX 2009, STOCKTON, CA 95201 <br /> : PERMIT IF IRES 1YEAR 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 herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services._ f <br /> X'Job Address d i�-H/� City ✓ Lot Size/Acreage <br /> I Owner's Name A_J, Address a <br /> k+ Phon <br /> f Contractor-L� TT(J'�np!� dress •-fl o Ts�w� �s3 ���6f1� 9,71 <br /> License No. Pli e <br /> TYPE Of WELL/PUMP: ^^ `NEW WELL',[]- WELL•FiEPLACEMENT .n� DESTRUCTION Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER El Monitoring well <br /> e DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUNfPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C� Industrial O Open Bottom7—%z❑•Manteca Dia.."of'Well Exca�Tgtion Dia. of Well Casing <br /> Cl <br /> Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing_ Specifica`tibns <br /> I'l Public Cl Other 11 Delta Depth of Grout Seal Type of Grout Q <br /> j I I IrriUation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction j Well Diameter _Z °� Sealing Material & Depth _�,d; T _9,7' y _ <br /> f Depth Filler Material i Depth qi. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewe <br /> available within 200 feet.) <br /> Installation will serve: Residence^ Commercial_ •Other <br /> Number of living units: Number of bedrooms <br /> i <br /> Character of soil to a depth of 3 feet:} Water table depth <br /> SEPTIC TANK © Type/Mfg- �'� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ell Foun ion Property Line <br /> i <br /> LEACHING LINE Cl No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance ip nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 DepthSize -1_Number. <br /> SUMPS LI Distance to nearest: Well Foundation R w Property Line <br /> DISPOSAL PONDS p <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 shelf not <br /> employ any person in such manner to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ca ' ' the following: '9 certify the performance of the work for which this permit is issued, i shall employ persons subject to workman's compansa- <br /> on laws f Cafifornis." <br /> The applic t call r all uired inspections. Complete drawing on reverse side. <br /> Signed Title: O -GT /�itt/!r�' <br /> � -� Date: e7 P <br /> FOR DEPARTMENT USE ONLY ++�� <br /> Application Accepted by Data ` oma' w Area <br /> Pit or Grout Inspection Date Final Ins ection b rtl 'tic F 6-as` <br /> p y�� Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services (_L Z1_ <br /> Environmental. Health Permit/Services S�Z 93 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE �' AMOUNT REMITTED CK RECEIVED By <br /> CASH DATE PERMIT'NO. <br /> GSC <br /> . EH 13.21 iREV.t i w 51 w �� Q <br /> U <br />