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} <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E <br /> CEIVED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN- JOAQU IN, PHONE (209)468-3420 S E P 2 2 1992 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPERM IT/SERVICE <br /> (Complete in Triplicate) <br /> G Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> k application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> I Joaquin County Public Health Services. <br /> Job Address W City r Lot Size/Acreage <br /> I. Owner's Name C-L/ Address./4 `I Address •u+n+4��1da/'�)� — Phone <br /> 4 Contractor (" ' Addres� r License N1 Phone <br /> k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION Sk SYSTEM REPAIR L1OTHER ❑ Monitoring well <br /> j . <br /> t DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. ="PROP`UNE' ..w <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> C} industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> A Domestic/Private ❑ Gravel,Pack ❑ Tracy Type of Casing_ Specifications-- -- -- - <br /> I"I Public 1.1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I } Irrigation Approx. Depth I I Eastern Surf a Seat Installed by <br /> Repair Work Done )e Type of Pump_.&L&e - H.P., State Work Don <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Finer Material & Depth �rZR fY —Iyf <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <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. ❑ r R .. Method of Disposal <br /> # Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L'1 No. & Length of lines Total length/size <br /> r� <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number. <br /> SUMPS 0 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 /> t 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 subcontracting signature <br /> F 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 /> k tion laws of California." <br /> r1 The applicant st II for all required inspections. Complete drawing o ver side. <br /> Signed X aTitle: Date: 1L>/ <br /> � R DEP <br /> Application Accepted by Date ea ` <br /> Pit or Grout Inspection by Date Final Inspection b Dat <br /> t- <br /> Additional Comments: <br /> g 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 � :?�3' <br /> Ai <br /> IFEO AMOUNT DUE AMOUNT REMITTED CK CEIVED 8Y TE PERMIT'NO. #i <br /> � £H t3.741AEV.�/n5 <br /> EH t4.2e <br />