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r APPLICATION <br /> SAN JuAQUIN COUNTY PUBLIC <br /> AISR� --� <br /> ENVIRONIdF.NTAL HEALTH I1 r.14� 7A 7 ,''] <br /> 445 N SAN JOAQUIN, PHONE ( a"T <br /> P O BOX 2009, STOCKTON, (A2520 <br /> PERMIT EXPIRES 1 YEAR FROWDAIA ISSUED <br /> (Complete in Trip1ica <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install v c ed. This <br /> application Is made in coMliance with San Joaquin County Ordinance No. 549 and 1862 and e s �e of San <br /> Joaquin County Public Health Services. <br /> Job Addresa P1 U -_ City _ Lot Size/Acreage / Lt <br /> I Owner's Name t`L� ? ! �LU } -- Address1� ,' a .hone <br /> it��ad-il � U�11e ttJa `��s�7� <br /> Contractor �� n Address t �- License Noi--5q3 S 3 Phone A <br /> TYPE OF WELLIPUMP: W WELL ❑ WELL REPLACEMENT DESTRUCTION XOut of Service Well ❑ <br /> PUMP INSTALLATTI-OWN � SYSTEM REPAIR O OTHER p Monitoring well <br /> / <br /> A DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP. LINE a0 <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1400 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial 0 Open Bottom 0 Manteca Dia. of Well Exc vauon /i is. of Well Casin <br /> `Domestic/Private Gravel Pack ' ❑ Tracy Type of Casing_ •�' Specifications <br /> I'1 Public CI Ot 3 � f-1 Delta Depth of Grout Seal Type of Grou <br /> I I Irrigation Approx. Delt�� <br /> th I I Eastern 1 urface Seal installed by e � Gn <br /> Repair Work Done U Type of Pump H.P, ai _-- . te W Dona <br /> Well Destruction Well Diameter Sealing Material 6 Depth /� ft-e-Yt ►' ./ iS <br /> Depth f ller Material i Depth o = <br /> TYPE OF SEPTIC WORK: NEW INSTALLA O I REPAIR/A DOITION l I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: WaftoT depth <br /> i SEPTIC TANK. ❑ Type/Mfg.._., - -- - Capacity Nq.,, o <br /> PKG. TREATMENT PLT. 0 <br /> Distance 10 nearest: Well Foundation Pro e A <br /> Cot I <br /> LEACHING LINE C1 No. & Length of lines To j Cz `AtT- <br /> .,FILTER BED n Distance to nearest: Well Foundation iriir� , I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Pro rty Line <br /> DISPOSAL PONDS ,zw. f 404 <br /> I hereby certify that I ve prepared this application and t at the work will be do a in accordance with San Joaquin county ordinances, state la ani <br /> rules and regulati of:the San Joaquin County <br /> Home owner o �censed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued, I not <br /> lw <br /> employ any rson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature00D''',`i� <br /> canities t following:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- T� <br /> t tion la of California," <br /> The pplicant must call or Talluir d inspections. Complete drawing on reverse side. <br /> Si ned Title: �� ' Date: <br /> - a <br /> -._..:. ..,...,...mow-u- <br /> h FOR DEPARTMENT USE ONLY <br /> Application pled by � Date Area r ', <br /> Pit or Gr tit nspec by 11' Date 1 �` Final Inspection by Data <br /> e <br /> 1 Additional Comments: <br /> ' Applicant - ftetr>,rin all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> H <br /> t� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 5 (/ <br /> f �7 �(o IFEE NFO AMOUNT DUE AMOUNT REMITTED Cx RECEIVED BY DATE PERMIT'/N'O`, 3$ <br /> � -� / � / � <br /> EH l4-Ie <br /> t+ S ! 7 ,l "7 4 s�� <br />