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l i <br /> APPLICATION <br /> SAN JOAQUIN COUNTY .PUELIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> v n„re-s.sa P�r� PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I10 200 (Complete in Triplicate) <br /> Applihereby 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address RV <br /> / 06A / <br /> City s-C'My Lot Size/Acreage <br /> Owner's Nalme1R0ZJVAddress '03 9 AffASA" C1 Phone <br /> Contractor �I`ity _/1 rti euz ddress ense N a✓LZ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT^ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER-❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�LERPROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> "A-Domestic/Private ill-Gravel Pack7 ❑ Tracy Type of Casing-RX Specifications,. <br /> I'l Public ( ther F1 Delta Depth of Grout Seal IeZ71 Z-frl­ - Type of Grout�f <br /> I 1 Irrigation Apprax. Depth 1I Easter Surface Seal Installed by <br /> Repair Work Done L] Type of Pump P. State Work Done_ <br /> Well Destruction D�L Well Diameter J�g Sealing Material & Depth � ,r{?,- <br /> Depth /fin Filler Material & Depth <br /> T 2 C7 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.] I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> 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 ❑ Type/Mfg _ - Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: `Well Foundation -Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 certif 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 ornia." <br /> The appli a st c or requ tions. Complete drawing on r rse Sid <br /> Signed X Title- Date: <br /> SE-ONLY qryA- <br /> Application Accepted by Date. Y5 1� Area <br /> -ILL avedl , <br /> Pit or Grout Inspection by Date Final Inspection by Lt, e`•=_;zn Pate . <br /> Additional Comments: <br /> Cwt k fx/e vSe C� � <br /> Applicant - Return all copies to: San Joaquin County Public Health Servi es .S/ail/" <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> EH 13'24 1AEV,f 1 H 5)U)K � e- -I?- <br /> - <br /> EH 1446 <br /> t/V �r �f ✓ [ r, / / <br />