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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',- STOCSTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> and/or install the work herein described. This <br /> Application is hereby made to San,loaquin county for a permit to construct <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name S�—_ Address. <br /> r. .. -..-�---- <br /> - --� �-, . • ----'- _. .__ .....r-.«..,e ( Phone <br /> L Address License.fVo. <br /> Contractor n _ <br /> .NEW.INELL�❑ `_WEL'L:REPLAGEMtENT_..,- - -t,-DESTRUC_TIONiC1 Out of Service Well _C) <br /> TY=PE`OF-WEI L-lPUMP:-- - a_ 07HEA ❑Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR <br /> . pI . PROP.-LINE <br /> SPOSALFLD <br /> SEWER <br />._,;rDISTANCE.70-NEAREST:�SEP,71CTANK_ : <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELD — PITSlSUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> F1 Industrial U Open Bottom ❑ Manteca Dia- of Well Excavation <br /> L7 Tracy Type of Casing_-- Specifications' <br /> C7 Domestic/Private ❑ Gravel.Pack Type of Grout <br /> Ll Other n Delta Depth of Grout Seal <br /> I'1 Public <br /> I Irrigation ,.Approx Depth 1 I Eastern Surface Sedi"installed by _ <br /> of Pump la! H,P. <br /> - _ State Work Done ' <br /> 1Repair Work Done L] T' D Sealing Material i Depth ��{ <br /> Well Destruction ❑ Well Diameter u <br /> Depth Filler Material 3 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIN/ADDITION i I DESTRUCTION I I afvaile <br /> sep`wshin system Ie itted if�•`public sewer is <br /> Installatiorti will server Residence "Commercial Other -- <br /> T. <br /> Number of living units: Number of bedrooms - <br /> 1 Water table depth <br /> Character of Soil to a depth#of 3 feet: <br /> ❑ aType/Mfg <br /> Capacity No. � rt <br /> SEPTIC TANK- Met o <br /> PKG. TREATMENT PLT. ❑ g r <br /> $Distance-to nearest: Well Foundation Property <br /> R <br /> +F Total length s ze <br /> LEACHING LINE 0 IVa. & Length of lines P� r Q�11� TY t <br /> FILTER BED n Distance to nearest. Well Foundation L jr` <br /> . ' � M DIVi 'IQ�! <br /> SEEPAGE PITS I I Depth Size Number <br /> � .T- <br /> 'J SUMPS` ^ L1 Distance to-nearest:' YWell " 'Foundalt ion <br /> f <br /> DISPOSAL PONDS ❑ _1/ <br /> I hereby certify that I have prepared this application and that the w�;aivill be doge in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> r�cert�y�that in the performance <br /> Horne owner or licensed agent's signature certifies the foliowing: 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 AOO <br /> "1 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 law ." �The appall for all requ' a inspects g)Co Plate drawing o re r e side. <br /> ' Data: <br /> Signed <br /> Title: <br /> _ FOR DEPART•ME . .USE.ONLY.L <br /> ..,.-� :-�-- <br /> _ .Application Accepted by � " a" <br /> Pit or Grout Inspection by ate Final Inspection by <br /> Data -3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> . Em 13.2,(REV.,,Hsb P �I s5f ' <br /> EK 14.26 <br />