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APPLICATION <br /> - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER ICT�$� µ <br /> ENVIRONMENTAL HEALTH IJIVISION tt <br /> 445 N SAN JOAQUIN,PHONE(209)469-342 FAC # <br /> P O BOX 388, STOCKTON, CA 95201-0388 µ ------. I <br /> PERMIT EXPIRES 1 YEAR FROM DATE I�Sd O/y/G� <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1 5.3 and the Rules and Regulations of San Joaquin County Public Health Services. 2,, <br /> Job Address s Ctyt Size/Acreage <br /> (% <br /> Owner's Name r v Address Phone <br /> Contractoass License No � 9v <br /> / <br /> Phone <br /> TYPE OF WELL/PUMP. NEW WEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION G SYST REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAIMateri <br /> ION SPECIFICATION$ <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. Excavation Dia. of Wall Casing <br /> ❑ Domestic/Private Ll Gravel Pack ❑ Tracy g_ f� 0 <br /> I'I Public FI Other fl Delta t Seal RECEIVED - <br /> I Irrigatron _ Approx. Depth I I Eastern nstalled by <br /> RepkN,Work Done U Type of Pump H.P, State Work Done _ f <br /> Well Destruction O Well Diameter SealinDepth CAN ir15f�IN rOUivlY \�` <br /> Depth _ Filler Material s Depth PUBLIC I-IEALT11 SERVICES Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION I 1 Ilea septic iystem perms a iF pubse•wr is <br /> . / available within 200 lest.) <br /> Installation will serve: Rmclencs ✓ CommercialCher <br /> Number of living units: _ Numbek of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg 2rCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �/�/1�(/`) Method o Dispose) <br /> Distance to nearest: LSL�J1ldntletion Property Lina <br /> LEACHING LINE 0 No. b Length of fines Y U <br /> A-IfT al length/size <br /> neu <br /> FILTER BED ❑ Distance to merest: Well ounoauon Pro Line <br /> tr <br /> SEEPAGE PITS 11 Depth Sirs 11 <br /> ' �1�L+,mber <br /> ce ne <br /> SUMPS LI Distanto er a Well Foundation L��`)/ Properly Lira <br /> DISPOSAL PONDS ❑ <br /> 1 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, 1 shall not <br /> empby any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 compenaa <br /> tion laws o1 California." <br /> The applicant must ca for W re dinspect= s. Complete drawing on reverse <br /> 'side. <br /> trt <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT <br /> DEPARTMENT USE ONLY (Q� ��_^) <br /> ((Application Accepted by �l_},lsr".¢9.` \ LsXJIIA_. h e t l] Date `�_�n—�`1 /\ Area <br /> �p-:� <br /> &ryor Grout Inspection ,L� �Date -`r Final Iropect=on by T /�/ � Date <br /> CAdditional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> 1 I Environmental Health Permit/Services <br /> "S N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 <br /> FE <br /> INFO AMOUNT DUE AMOUR NT REMITTED SH RECEIVED BY DATE PERMRNO. m <br /> Marr ieFv. ,.si A)� jIII 1)7) InfAA I /f I) 7 I q,?,X.aA I Ir., - i "' <br />