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APPLICATION <br /> ECEI � JOAQUIN COUNTY `PUBLIC HEALTH SERVICES <br /> 1� ENVIRONMENTAL HEALTH DIVISION <br /> A��9 2 a x@457' SAN JOAQUIN, PHONE (209)468-3420 <br /> 10A41N CO <br /> , 5,B0% 2009,.,,STOCgTON, CA 95201 <br /> V,•dV51R4 FERbdIT EXPIRES 1 YEAR FROM DATE ISSUED- <br /> (Complete in Triplicate) <br /> � 1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> gl ! <br /> application is made in eempliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ( City e Lot Size/Acreage <br /> }.1 r <br /> Owner's Name _ Address �7"�•� r` -77 , -- Phone <br /> k <br /> Contractor sMues ense No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTIONZF60ut of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well E� <br /> -.. —DISTANCE TO NEABEST:�SEP7IC�TANK��:SEWER E.INES� DISPOSAL-FI-P.- <br /> FOUNDATION <br /> ISPOSAL FLP,FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> Cl Industrial ❑ Open Bottom ❑ Manteca,,: Dia. of Well Casing <br /> '� Dia. of Well Excavation_.._� g <br /> [.1 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> l•1 Public f.1 Other n Delta Depth of Grout Seal Type al Grout <br /> I I Irrigation ApproJDepth .I 1 Eastern Surface Seat Installed by <br /> Repair Work Done LJ Type of Pump -° H.P. State Work Done — <br /> Sealing Material & Depth r <br /> Well Destruction toa-- Well Diameter <br /> ; <br /> Depth T/1 "�-y _ - ,Filldr Matexial 5 Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I ! DESTRUCTION I I INo septic system permitted if public sewer is <br /> i i available within 200 feet.! <br /> Installation will serve: Residence_ Commercial_ Other { <br /> I Number of living units: Number of bedrooms "" t <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. ❑ - Method of Disposai <br /> Distance to nearest: Well Foundation Property Line' <br /> E LEACHING LINE D No. & Length of tines $ k Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br />' I <br /> SEEPAGE PITS 11 Depth Size Number <br /> -'--_�! _ ::. ..-..,.-:yam. •--..--�_ <br /> ; --suMPS ('I Diaibhce ta'rieari�ai' � Well = 1 °"'"�Foundatian"" Property Cne <br /> DISPOSAL PONDS ❑ <br /> 1 . <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 taws 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 /> The appl" t ust f all.re, it dr coons. Complete drawing on re side. <br /> Signed Title Date: <br /> ',F/ly 4714?2- <br /> FOR DEPARTMENT USE ONCY <br /> Application Accepted by - Date `r Area ?0 / <br /> I <br /> PitoQ., <br /> 1 s ction by Date Final Ins ction by Date <br /> Addkomments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San''Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT NO. <br /> r INFO <br /> U)IO <br /> EH 13-24 IAEV,r K 51 O✓� �� e <br /> + EN 14.26 <br />