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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ii ENVIRONMENTAL HEALTH DIVISION <br /> 2445 N SAN JOAQUIN, PHONE (209)468-3420 PAYMENT' <br /> 1P O BOX 2009, STOCKTON, CA 95201 <br /> ,. RECEIVED <br /> SPERM I T ESP I RES 1 YEAR FROM DATE I S SUED J A N 12 1993 <br /> (Complete in Triplicate) SAN JOAQUIN COUNTY <br /> I <br /> i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install �� kTd4s%��SThie � <br /> application is made in coe�liance with San Joaquin County Ordinance No. 549 and 1862 and �1 � ����1� <br /> Joaquin County Public Health Services, <br /> P <br /> Joh Address . .,�� City � Lot Size/Acreage <br /> c <br /> Owner's Name �' � °� Address /kms-�>� Phone <br /> Contras Addre icense -. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DLVSTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> I <br /> DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> Cl Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing_ Specifications <br /> I'I Public FI Other , n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation /� Approx.',Depth I Eastern Surface Seal Installed by <br /> Repair Work Done � Type of Pump H.7~ State Work Done V'PP <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> r { available within 200 feet.) <br /> Installation will serve; Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ! Water table depth <br /> SEPTIC TANK. ❑ T <br /> ype/Mfg j Capacity No. Compartments <br /> PKG. TREATMENT DLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Le nlgth of lines } Total length/size <br /> FILTER BED n iDistance to nearest: Well Foundation Property Line <br /> Kj t <br /> w <br /> SEEPAGE PITS It ' Depth rf Size ` Number <br /> w <br /> SUMPS Ll ° Distance tti nearest: Well w Foundation Property Line <br /> DISPOSAL PONDS ❑ . � <br /> I hereby ceriify 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:Bars-Joaquin) County <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performan6a of the work for which this permit is issued`I shall not <br /> employ any person in such manner as twi ecoms subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I ceitify that in the performance of the work for which this.permit is issued,-I shall employ parsons subject to workman's compensa- <br /> tion laws of Cafifornia." <br /> The applicanum -fo II required inspec 'ons. Complete drawing on rree side. <br /> Signed Title: 17 <br /> Date: A Lt—Z,3 " <br /> s <br /> FOf4 DEPARTMENT USE ONLY f <br /> Application Accepted by Date C Area ` <br /> Pit or Grout Inspection by Date Final Inspection by e Date -3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2008, Stkn, CA 85201 <br /> )111 <br /> IFEE AMOUNT DUE 't AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> . EH 1324{AEV.tir51 � Liz— r....1 ! . r /' 7G] ✓ F /7 r�3 ���-�91t7 <br /> EH 1426 r ! !J .? v V <br />