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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE,VICI j <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,PHONE(209)469-3 0., � ) <br /> P O BOX 388,STOCKTON,CA 95201-038$ <br /> f r PERMIT E%PIRES 1 YEAR FROM DATE i88V <br /> (Complete in Triplicate) # _- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri6'.- is app rcauon rs ma e m compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address /` Cit Lot Size/Acreage <br /> z4a <br /> Owner's Name �� , Address Phone ) y <br /> ! < r <br /> Contraclor � lit. Address ! License No2� Phon <br /> . <br /> TYPE OF WELL/PUMP, NEW WEL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service WW11 Irl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E) Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES C DISPOSAL FLD. PROP. LINE <br /> FOUNDATION .`;,�O AGRICULTURE WELL OTHER WELL dam., PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> Q�4-GQmeatic!PrivateGraval Pack ❑ Tracy Type of Casing Specifications ', <br /> ('1 Public 1-1 Other f7 Delta Depth of Grout Seal r� Type of Grout <br /> I i Irfigation � JARprax. Depth I I Eastern Surface Seal Installed by <br /> I Repair Work Done L) Type of Pump H.P. _w State Work Done <br /> i Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth_ l 5 Filler Material i Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public "war is <br /> available within 200 feet.! (� <br /> 1 Installation will serve: iissider►ce— Commercial_ 011ie( IR <br /> 1 Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 �0 <br /> Nasal <br /> Distance to nearest: Well Foundation Props noVT <br /> f_:,Fj <br /> LEACHING LINE 0 No. & Length of lines Total length r <br /> 91 <br /> FILTER BED 0 Distance to nearest: Well Founaation P1Q M#Li <br /> TY <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS LI Distante to nearest: Well Foundation Property Line <br /> �. DISPOSAL PONDS ❑ <br /> I hereby cenify that t 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 eenify that in the performance of the work for which this permit is issued, !shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I canify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mut tail for all required inspgctions. Complete drawing o rever3?fiide. <br /> Signed X_ �-C- ^� Title: � �`�,Lr-l�i� Data: <br /> 7 FOR DEPARTMENT USE ONLY <br /> Application Accepted by t ill ° Date ° "`~ ! %° Area <br /> Pit of Grout inspection by ? Datef'0 LJ 9` Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies.to: San Joaquin County Public Health Services ��" <br /> J Environmental Health Permit/Services <br /> { 445 N.San Joaquin,P.O.Bax 388,Stockton,CA 9521)1-0388 s-0)000 � 7 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> IN O 1-11 CA51♦/ DATE PERMIT"N0. r <br /> _EM 13"711REY.1in5rLIU �/� ` � L�.ln�f� �� <br />