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4, <br /> APPLICATION <br /> 3a <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, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I SUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork 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 /> Job Address 116 -L LoWfX, S*C, RD City - Lot Size/Acreage <br /> Phone <br /> Owner a Name Address �hone <br /> Contractor L'L KiLl AfvL Addre]stl' f 1 W-1 C ense'r4o L, <br /> TYPE OF WELL/PLIMP: NEW WELL 0 WELL REPLACEMEN.T171 DESTRUCTIONQ�t of Service Well 0 <br /> PUMP INSTALLATION 1:3 SYSTEM REPAIR C1 OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL- PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> CI Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation <br /> Specifications <br /> -,l Domestic/Private 0 Gravel,Pac� 0 Tracy Type of Casing <br /> ('I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> _rV'gj��, ^r7 <br /> Repair Work Done! Q Type of Pump -H.P. State Wor.k-Done r ras5w <br /> Well Destruction Well Diameter v Sealing Material & Depth <br /> Depth It Filler Material & Depth Coot <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOtTION 1.1 DESTRUCTION I I (No septic �ystem permitted if pLiblic sewer is <br /> available within 200 fset.� <br /> Installation will serve: Residence— Commercfal Other--- <br /> Number of bedrooms <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> 0KG, TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation— Property Line <br /> LEACHING LINE El No.'& Length of lines Total length/size <br /> FILTER BED F1 Distance to nearest. Well Foundation— Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereb I have prepared this application and that the work will be done in accordan.ce with San Joaquin county ordinances, state laws, an <br /> rules a r cer"ifat an on <br /> L r,, da� Q * <br /> an Joa uin Cor certify that in the partormancetf'the work for which this permit is issued, I shall not <br /> .Horri o_neJ a,Ii psns ig atu. rti;.1 the Iollting- <br /> n n I -contracting signature <br /> empl�ev an -J s ch ma nor s t a sub.i" ,k*.,n's compensation taws of4alifornii." Contractor's hiring of sub <br /> cenifies the 1 11 ing: " artif t in a o once o a work for wh ued, I shall employ persons subject to workman's compensa- <br /> tion laws of ornia." <br /> The appli a t f r all r 40 Co Iota d ng <br /> ins 0 rawi on is perT <br /> 1110 �� ief — Data: <br /> Signed f IV Title: <br /> OR DEPARTMENT USE ONLY <br /> b 11 06" Date . 4 Area 13 <br /> Application Accepted () — <br /> Pit or Grout Inspection by Date Final Inspection by 1A A A If I Date <br /> Additional Comments: V <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 /> FEE AMOUNT DUE C" PERMII'NO, <br /> INFO AMOUNT REMITTED CASH RECEIVED BY OATE <br /> t;e507 <br /> 51 Ak <br /> EH 13-24 tREV.I 5JW4 1) f or-I <br /> EH 14-26 �2�2 .0 rT2 <br />