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S AQUIN COUNTY PUBLIC HEALTE�RVICES <br /> ENVIRONMENTAL HEALTH D I V I S I`ON E PA LZ"� <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 v o <br /> P O BOX 2009, STOCKTON, CA 95201SAN�P 15 1992 <br /> uQE QJrf-1 CPERMIT � Y � FO� AISSUED lP0206NA� LOLIN T'V <br /> (Complete in Triplicate) JV1�D�rO: ATF-HR`rC=S <br /> D11,;6 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. art PJ <br /> application is made in compliance with San Joaquin County Ordinance No. 50 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. <br /> Job Address IMyCity Lot Size/Acreage I <br /> I 7 i <br /> Owner's Name Address • Pho 1 <br /> d <br /> Contractor Address License No. tPh <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C] Monitoring Well C3 <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS I N 110 <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. ol Well E ca, iffl i I as ng <br /> [I Domestic/Private ❑ Gravel Pack C1 Tracy Type of Qa iLAr s <br /> 1" w <br /> f�g�" ,.— T e or i <br /> I'I Public f-1 Other fl Delta Depth <br /> 'oFG'r'r�h�Gir eSr MI yP <br /> 1 1 Irrigation _ Approx. Depth I I Eastern Surfac$r'atieatt;llblwbx VXPj e i <br /> Repair Work Done L3 Type of Pump H.P. t f' ` <br /> Well Destruction ❑ Well Diameter <br /> Sealing Maters •1 <br /> Depth Filier Materiel & Depth "` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONA REPAIR IADDITION i I DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> available'Within 200 feet.) <br /> Installation will serve: Residence Z Commercial_ Other <br /> Number of living units: —I-- Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. X Type/Mfg Ot Capacity .�do. Compartments <br /> PKG. TREATMENT PIT. Cl if Method of Dir <br /> Distance to nearest: Well Foundatiori: "i Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br />�. v. .DIS005Al PONDS ❑ <br /> I hereby cenity 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 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa- <br /> tion laws of California." <br /> The applicant ust for all re fired inspeeli Complete drawing on reverse i e. <br /> a� .� <br /> Title: Date: <br /> I <br /> Signed ��� - - <br /> 4 <br /> R D ARTMEN SE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <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 /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEI Eg BY ATE PERMIT'N0. <br /> INF) I t <br /> • EH 13.24 IREV. <br /> EH 14.78 <br />