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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009,-STOCSTON, CA 95201 <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 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 Health Services. <br /> Job Address LL4& a d='"P,iA - f't` C-Cr l-7-rf-'- City Lot Size/Acreage <br /> Owner's Name C J(/ -f Ao Address vL& Ce n 2SPt JPhone L_ <br /> Contractor O l(.Ja2 lei- _Address LL License No. _i�Phone �7 C/1 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES iLo+ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS-SUMPS <br /> INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCTION SPEC1fICATlO 91 <br /> Ll Industrial ❑ Open Bottom Manteca Dia. of Well Exc...riion Dia. of Well Ca� . <br /> `� c/Pr6 1FJWJ_ <br /> ivateGravel Pack ❑ Tracy Type a1 Casing,_�1 d'?f Specifications <br /> �7Y�?ublic f-1 Othef 1� Delta Depth of Grout Seal Type of Grout <br /> t I Irriga � n ,TkrApprox. Depth 1 .1 Eastern Surface Seal Installed by'--,-- <br /> Repair <br /> y' ,Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION t 1 (No septic system permitted if public sewer is <br /> available within 200 feet,I 3 <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 D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE. Cl No. & Length of lines Total length/size <br /> FILTER BED (_7 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size_T Number <br /> SUMPS ll Distance to nearest: Well Foundation Property Line <br /> 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 <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." <br /> 4 <br /> The applicant s all for 11 rerit06 inspections. Complete drawing on a rse side. f C� <br /> Signed X Title: ____ Date:000, <br /> R DEPARTMENT USE ONLY Iq <br /> Application Accepted by Date " Area <br /> Pit or rout spec#ion byDate17� Fines inspection by Dat17 <br /> ej_ / d�L�Z <br /> Additional Comments: <br /> Applicant - Return a 1 copies to: San Joaqu n County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEt <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EH 13-14 IAEV.I I x 51 t`� <br /> EH 14.28 W LJ v <br />