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APPLICATION <br /> JOAQUIN COUNTY PUBLIC HEAL $ SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95203 <br /> 1-j—57- <br /> PERMIT <br /> .j— <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 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services / <br /> �/� <br /> � 7`. ' / <br /> Job Address 9 City <br /> TTU3 <br /> Lot bite/Acreage/F/C c <br /> Owner s Name .L/,'- rem�— - Address l r' f}1 P Phone <br /> ConIra[toJ{f��ii� ZEY-�f:4Tlf Address3 -'S�/ �/T- �/'�41f1 Z?, License NoZ,�'Z77-7OL Phone <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL// DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> tRdusuut%)CN�TD? ❑ ppan Bottom CI Manteca Den of Well Excavation_ f3 " Dra of Weil Casing <br /> Fl Domestic/Private Gravel Pack ❑ Tracy Type of Casing- 2 ,2c/±40Specitications <br /> I I Public fl Other ;it pelta Depth of Grout Seal �rJ " ��/ Type of Grout/&��r <br /> I I Irr11Jdtion .A.Approx Depth I I Eastern Surface Said Installed by X,11�71 Pc.✓a.�l. <br /> Repair Work Done 0 Type of Pump H P State Work Done <br /> Well Destfuct+on ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> T F SEPTIC WORK NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION:7No <br /> ptet system permitted +f public sewer <br /> ble within 21X1 feet i <br /> Installation will Residence Commercial Other <br /> Number of kvmg units Number of bedrooms <br /> Character of soil to a depth of 3 feet er table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well t+,n Property Line <br /> LEACHING LINE C1 No & Length of lines length/size <br /> FILTER BED n Distance to St Well Foundation Pro Ltne <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> D �LPDS ❑ <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 /> employ any person in such manner as to become subject to workman s compensation laws of California Contractors hiring or subcontracting signature <br /> certifies the following 1 certify that in the performance of the work for which Ilii$permit is issued I shali employ persons subject to workman s compensa <br /> tion Isws of California <br /> The applicant u all for sit required inspections Complete draw+C�nd4 on inverse side <br /> Signed X. �'�-��!' IJ '�`�"1f-�) U��i`��v�. �ille �rG� r� I`'`��- � Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pei or Grout Inspection by Date 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 0 Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE PERMIT NO <br /> EM 13 24 trtEV +/K SI <br /> EM 14 Z0 <br />