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��,,, _ acs— -•,, <br /> ` APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ��� /� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU <br /> (Complete in Trlpl>cate) <br /> Application in hereby made to S I Joaquin County for permit to construct and/or install the work herein described. This 1 <br /> application Se made in compliance with San Joaquin County Ordinance No. 549 d the Rules and Regulations of San <br /> Joaquin County Public Health Services. 1t'1 S Lot Size/Acreage Vq tT CrL <br /> 10 866 N sT 2T g!2. City <br /> X,1ob Address _�---� CC./p ��� ���� D.1 _07�T— i�tZ J I _ 0 c—�V 1I Phone <br /> Address <br /> wner's Name .. .. <br /> i License No. Phone <br /> Sl" Address <br /> 11 onnactor WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service.Weil <br /> TYPE OF_ WE�IJ PUMP. ;NEW WELL ❑ OTHER ❑ Monitoring Well n <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION. _ AGRICULTURE-WELL• OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bononi:"O Manteca' - 'Dia'of`Well Excavation <br /> CV Industrial / Type of Casing <br /> SPacilkations <br /> ❑ Tracy g <br /> LI Dom site/Private ❑ Gravel Pack G Depth of Grout Seal Typa of Grout <br /> 11 <br /> 11 Publico fl Other < !. fl Delta ! 11. / <br /> lrcipa(ion —Appo ..Depth I I Easter. Surface Saul.Insnllad�'S <br /> H P 'State Work-Done <br /> Repair Work Done L3 Type of Pump Well Diameter Sealing Material a Depth r �-�`- <br /> Well Destruction O Piller Materiel a.Depthj <br /> Depth <br /> \ v. available within 200 feet.l �1 <br /> TYPE OF _SEPTIC WORK:/NEW INS{TALLATION I 1 REPAIR:ADDITIONA-l' DESTRUCTION INo septic system permitted it public sewer is 1 <br /> ICommerc al-_ Uther <br /> Instaaatibn will serve:` Rau^dence_. <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of wit td a depth of 3 last.' f`,. y Capacity_ No. Compartments <br /> SEPTIC TANK O Type/Mfg �.y� ei -i ?!Msthbd"dt0iip0sa1 <br /> PKGI TREATMENT P .❑— Foundation 'Property Lirwi <br /> I <br /> Distance 10 nearest: Well - <br /> ' a Total length/sire <br /> LEACHING LINE 0 No. BiLength of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> Number �{ <br /> SEEPAGE PITS 11 Dep1M1 Sire <br /> Foundation Property Line <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑ 11 <br /> 1 hereby certify that I heve 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 Sen J08qum County <br /> iignaturlotlowing: "I certify that m is the performance of the work for which this permit is sued, I snail not <br /> Home owner or licensed agent's e cettilies the <br /> ce <br /> employ esathe following"tc certify thorn the performance of oche work efor which ethis permit ation is issued, <br /> I shall employ apoisons lsubject to workman1f compen6a <br /> tion laws of California." IIII <br /> The applicant t c II for all required ins china. omplets drawing on reverse side. <br /> Title: O�'8�P Date: <br /> I /y5igned X .�. <br /> (^ _- DEPARTMENT USE ONLY <br /> Date 1 —01L. Area <br /> Application Accepted by �A <br /> I Final Inspection by Dan <br /> Date - - <br /> Pit or Grout Inspection by 1 <br /> I <br /> I Additional Comments: I <br /> Applicant - Return all ��oPles to: San Joaq <br /> Eavl raametalounty Health blic Health Vice. s <br /> permit/Services <br /> lces <br /> n445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ZFE AMOUNT DUE AMOUNT REMITTED <br /> CA51/ flECEIV ED BV GATE PERMIT-N0. <br /> -t I2- OEH ty2x AEV.rreel � � l ^�^ IEH 1426 - - <br />