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APPLICATION- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,� (complete in Triplicate) i <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 1662 and the Rules end'Regulations of San <br /> Joaquin County Public Health Services. <br /> �lei pct di ISI City 1'77- �00'-0/ <br /> Job Addfess Lot Size/Acreage <br /> 03 <br /> 8 <br /> Milan a� Prj esr ir?�r � V m� <br /> 61 , �1 k!►x h Of�JIUUJ Chrt'st 44F Phone <br /> Owner's Name ')A d '" Address <br /> _50Q/52 _578-05 fa <br /> Contrat(af t Address l al r?? f' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WILL fTEPLACErMEffT / DESTRUCTION ❑ out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Elf OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST; SEPTiC TANK �'SEWEit-LANES" '�"" "`"""`DISPOSAL-FL'D:- "'�"'�PROP-ONE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Botiom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i <br /> lPubllc lOthert✓iCtST(N4 Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation / __ Approx. Dep I I Eastern Suri er�Seuf Installed by <br /> Repair Work Done V Type of Pump H•P, nLJ State Work Done _ <br /> Well Destruction E) Well Diameter <br /> Sealing Material 6 Depth t <br /> Depth I Filler Material & Depth W , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 , REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is Q <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence! Commercial T Other <br /> Number of living units: Number of bedrooms PAYMENT <br /> Character of soil to a depth of 3 feet: Wale <br /> SEPTIC TANK ❑ Type/Mig Capacity No. �II <br /> PKG. TREATMENT PLT, Ll Meth DRpc3al l J <br /> Distance to nearest: Wel! Foundation PropertvSftt)AQ13� NTY I I fL11 <br /> LEACHING LINE ❑ No. & Length of lines• Total IengN DIV451QN { <br /> FILTER BED ❑ Distancel to nearest: Well Foundation Property Line <br /> —-SEEPAGE PITS L l-: Depth Size Number _ .- <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O I . <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 /> F employ any person in such manner as 6 become subject to workmen'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." I 'w. <br /> The applicant must call for all required,inspections. Complete drawing on reverse side. <br /> Signed } Title: eaL Date: /:22?Z-�� <br /> I ; <br /> fOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r rea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r <br /> Additional Comments: r � <br /> F <br /> Applicant -- Return all copies to: San Joaquin County Public Health\Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> s <br /> k FEE AMOUNT Dt1E AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> INFO <br /> - ' EEH 3-24 H t3.24(REV.I/n 5) �, <br />