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-37-1996 8:42AM FROM P. 2 <br /> • APPLICATION • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMI_T_MPIRES 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 /> ttpplieation is leader in compliance with Son Joaquin County ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health "lees <br /> as�oo �,swb Ru <br /> Job Address City_,ZXACY Lot Size/Acreage <br /> Owner's Nome RW Address P-n_ RnX Phone <br /> Contractor�.'T4r Address ,lo. Phone <br /> TYPE OF <br /> WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT'M DESTRUCTION Ll Out of Service well ❑ <br /> T . . PUMP.INSTALLATION O SYSTEM REPAIR ❑ OTHER Moni�tor-i+qn�g�. Well oyr <br /> DISI-ANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. _ PROP. Llj�"� W r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS yr veru <br /> '.W TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Za2 q q,� <br /> ustrial O Open Bottom 0 Manteca Dia. of Well Excavation <br /> tee f omastic/Priivate M Gravel Pack O Tracy Type of Casing Specifications <br /> IttaC�1 A,blic I'l Other 11130118 Depth of Grout Seal Type of Grout <br /> Ork I I Irrigation ,..,_,Approx. Depth I I Eastern Surface East Insisted by <br /> tan Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Woll Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Piller Material 4 Depth <br /> OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is <br /> available within 2W feet,I <br /> ..�•:vtstion will serve: Residence_-_- commercial— Other <br /> nber of living units: _ Number of bedrooms <br /> recter of nos.to a depth of 3 feel: Water table depth <br /> C TANK O Typo/Mfg Capacity No, Compartments <br /> 9/i5 t TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of tires Total length/size <br /> f•U.T'.R BED O Distance to newest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number. <br /> SU llS L.1 Distance to nearest: We Foundation Property Line <br /> DISPOSAL PONDS D <br /> I hsratby curtsy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ,w, m%d regulations of the San Joaquin County <br /> W itw owner or licensed agent's signature amities the following: "I Certify that in the performance of the work for which this permit is issued, I shall not <br /> ehMcy any parson in such manner as to become wbiect to workman's compensation laws of California." Contractor's hiring ow subcontracting signature <br /> cenil,as the following:"I candy that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's eomponaa- <br /> ur.r ;awn of CalihtrNa." <br /> The t:pplicant moat Ca or all r fired 7tspa t . Complete drewklg on averse side. <br /> Siga,s,^P Title: 2&67N <br /> Pate: <br /> FOR DEPAT USE NLY <br /> Appot:.ation Accepted by Date At L <br /> (� u .tit,. /(d <br /> flF 'r Grout Inspection by /" Date o .Final Inspection by ���1 Date Z� <br /> Adalekonal Comment; C_.o f`-��c c..� � � -�,a., � � 4r�,. � i <br /> ,tplic.ant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 h Ban Joaquin, P 0 Box 2009, Stkn, CA 95201ote ? <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO, Page IJA <br />