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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION /U <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, 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. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health jServices. & <br /> Job Address ����� ^"�"• �+ �+ �'__ ,� ar�YC�ityy� Lot Size/Acreage <br /> 14 yxv ItrQe tu, _ J <br /> Owner's Name I'� Address fgk&,,,X.2 �� ��__ Phon "/ �xr <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well <br /> PUMP INSTALLATIO ❑ SYSTEM EPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES 150 DISPOSAL FL ON _ PROP. LINE <br /> { FOUNDATION AGRICULTURE WELL& OTHER WELL+ '_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICAWU <br /> 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well CasingL <br /> El Domestic/Private ❑ Gfavel'Pack? ❑ Tracy Type of Casing__ PIV Specifications. +� <br /> Ul Public Cl Other 171 Delta Depth of Grout Seal Type of Grout A631!6 C. <br /> I I irrigation "gAppcox, Depth l I Eastern Surface Sedi installed by , <br /> Repair Work Done L] Type of Pump H.P. Stale Work Done <br /> Y _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depthj � <br /> Depth Filler Material & Depth!y' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I Y REPAIR/ADDITION I I DESTRUCTION I I (Noseptic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> k Number of living units: Number of bedrooms <br /> 4 Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg E Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 71 Method of Disposal <br /> Distance to nearest: Well Foundation Property LPAY_R4S= ' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation PropenlIAL 1 3 1993 <br /> SAN JOAnl itru rnd.NgY <br /> 'SEEPAGE PITS 1 1 Depth -SizeNumber PUBLIC HEALTH <br /> SUMPS Lt Distance to nearest: Well Foundation r-IVrlHpV#MWAL HEALTH DIVISION <br /> DISPOSAL PONDS ❑ <br /> 4 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 shell 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 /> The applicant mus all for 1 r 8d inspections- Complete drawing o averse 'de. <br /> Signed X- _.,. Title: Date / <br /> FOR DEPARTMENT U F ONLY 4 <br /> Application Accepted by Date A0 <br /> ea <br /> Pit or Grout Inspection by Date Final Inspection by ! Data <br /> Additional Comments <br /> Applicant - Return all copies to; San Joaquin County Public Health Services tt pt�(J <br /> Environmental Health Permit/Services ��))�� <br /> s 445 N San Joaquin, P O Box 2009, Stkn,, CA 952010pig r /-,V9,V/��f <br /> IttfG�J INFO AMOUNT DUE AMOUNT. CASH FEE <br /> CK RECEIVED BY DATE PERMIT'NO. 0 f <br /> �q <br /> • OU <br /> EM 13.24 1"EV.1en s! �� /� 7��yy /� /� <br /> EM 14•7e tJ Y I , f <br /> �- l3.� <br />