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APPLICATION <br /> SAN JO,AQUIN COUNTY PUBLIC HEALTH IS D <br /> ENVIRONMENTAL HEALTH DIVISI <br /> / 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 MAR 2 4 1994 <br /> Rwa. EXPIRgSYEAR FROM 12ATE INUED ENVIRONMENTAL HEALTH � <br /> I '^r (Complete in Triplicate) PERMIT/SERVICES I <br /> f <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> ayp]rlcatiou is made in compliance with San Joaquin County Ordinance No. 50 and 1862 and the es and Pv+gulations of San <br /> .=Vin County `Public Health Services. y S�� <br /> Job Address 1 `50 S- ( City i*ot Size/Acreage l ,FK <br /> �j1� 0. � b <br /> owner.Name � �, Address e , �� Phone 1 o <br /> J �� Af6AJ40-�- 9456 0 <br /> v1 Contractor Address Pao"? <br /> No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.,LINE <br /> FOUNDATIOfy_ ,AGRICULTURE,WELL. OTHER WELL , PITS!_SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications_. <br /> I'1 Pub tic [1 other n Datta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth 11 Eastern Surface Seal Instilled by f <br /> Repair Work Done U Type of Pump H.P. - State Work Dona <br /> Well Destruction ❑ Wait Diameter Sealing lilaterial i Depth t R <br /> t Depth Filler Material i Depth <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION f I REPA(RlADOITION YJ DESTRUCTION I I INo septic system permitted it public sewer is <br /> V/ < available within 200 loot.) <br /> Installation will serve: Residence-L Commercial T Other 1 <br /> Number of living units: Number of bedrooms <br /> Character of sell to a depth of 3 lest: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Comparvmnts <br /> PKG.TREATMENT PLT,0 - Method of Disposal <br /> Distancs to nearest: Well Foundation Property Line (� <br /> LEACHING LINE No. &Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS El Well Foundation Property Line <br /> S <br /> D POSAt PONOS -ia. Distance to nearest. <br /> -- _ <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 /> ruts$and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit Is issued,4'shall not <br /> employ ° <br /> p oy an y person In such manner as to become subject 10 workman's compensation laws of California."Contractor's hiring or sub-contrecling signature <br /> eertifras the following:"s certify that iA he performance of the work for which this permit Is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California," <br /> / The appli ant us[call for all required€nspection$. Complete drawing on reveffle side, <br /> / \ Signed ' <br /> Title: Date: <br /> i <br /> FOR DEP{r<fi7MEN1 USE ONLY, <br /> .1�9� <br /> Application Accepted by t- + y l Dose Araa <br /> or <br /> Pit or Grout Inspection by 40 1 Dare+fJ^ �. inal Inspection by Data <br /> Addltk nal Comments: ' <br /> t <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> ,Enviroemetal_,lie,gl,tb Permit/Services <br /> 445 4-1aia'Joaquin, P`b Soo 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED + RECEIVED BY DATE, PERMI7'NO. <br /> INFO CASH <br /> I <br /> EM.4X I11EV. 4 s .< <br /> I <br />