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APPLICATION <br /> USAN JOAQUIN COUNTY PUBLIC HEALTH SE VICES � E�— <br /> V <br /> 00 <br /> ENVIRONMENTAL HEALTH DIVISIO I�1 D #445 N SAN JOAQUIN,PHONE(209)469-3 0P O BOX 388,STOCKTON,CA 95201-038 FAC,#PERMIT EXPIRES I YEAR FROM DATE ISS <br /> N <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 a w t ❑ <br /> Joaquin County Development Title Section 9-I110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Pubt <br /> Job Address City r • <br /> `^ rLot Size/Acreage <br /> Owner's Name _ALat'd c—(91- <br /> Address z' -e- Phone <br /> Contractor__..ln�, �2� E%jjl e( Address License No. OC Phone -777 <br /> ['ITYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT � DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> + C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> • _ Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> (1 Public [:1 Other - Specifications <br /> f1 Delta Depth of Grout Seal Type of Grout <br /> - <br /> Repair <br /> I Irrigation ^Approx. Depth I I Eastern Surface Sea] Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done, <br /> Well Destruction ❑ Wel! Diameter Sealing Material i Depth <br /> Depth_ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITIO l I DESTRUCTION I I (No septic system permitted if public jis <br /> available within 200 feet.] <br /> Installation will serve: Residence�Commercial_ Other�w <br /> Number of living unite: Number of bedrooms ; <br /> Character of soil to a depth of 3 feet:S cn�(9r (�p yt�' e <br /> SEPTIC TANK t - ,..—Water table depth <br /> Type/Mfg �P 1 e•tL2- CapecitY. <br /> f KG. TREATMENT PLT, [1 2'+a�— No. Compartments �- <br /> Distance to nearest: Well fi +• Method of Disposal <br /> Foundation-•, _ Property Line -T E* <br /> i LEACHING LINE P No. 8 Length of lines <br /> i, FILTER BED Tptal length/size <br /> C) Distance to nearest; Well f <br /> 1 � Favnaation Property Lino ^ <br /> � <br /> SEEPAGE PITS ! I Depth Sire Number_�� _ <br /> SUMPS <br /> ll�r Distance to nearest: Well _ Foundationl (}�` Property Line14MENT <br /> is DISPOSAL PONDS O <br /> I; I hereby certify that I have prepared this application and that the work will be'done in accordance wFth San Joa ui �+ <br /> rules and regulations of the San Joaquin county q *6611 state laws, and <br /> JJ+, Home owner or licensed agent's signature certifies the following; "I certify that in the "O <br /> this any person in such manner as to become subject to workman's com performance of the work for rbtiE47this err f issued, I shall not <br /> certifies the followin pehis pen laws ss California." Conlr �'� ontracting signature <br /> g: "I certify that in the performance of the work for which this permit is issued, !shelf amplp � � ckatfi's compensa• <br /> tion laws of Cplifornla." <br /> The applicant must call for all r ENVIRONMENTAL HiALT plv 5 <br /> required inspections. Complete drawing on reverse side. fON <br /> Signed <br /> Title: Ty Vtz-l' <br /> Data: <br /> FOR DEPARTMENT USE ONLY <br /> ARplic Accepted by C Date <br /> f Area ZI <br /> a r r t �n by 7 Date � � { <br /> Fina! lnspectian by ate "g S/ <br /> �! Additional Comments: <br /> 1' Applicant - Return all copies to: San Joaquin Cou y Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201.0388 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> ` CASH RECEIVED BY DATE". PERM17'N0. i cr) <br /> H t]•N IrlEv. <br /> `J a <br />