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J <br /> APPLICATION ^�- <br /> SAW-J OAQU IN COUNTY PUBLIC HEALT �,RYI <br /> ENVIRONMENTAL HEALTH DIVI I # S _ <br /> 445NSAN JQAQUIN, PHONE (209) 42(1"""'"""�'"'��'� '"—' <br /> P O BOX 2009, STOCKTON, CA # <br /> PERMIT EXPIRES 1 YEAR FROM DATZ IMM <br /> (Complete in Triplicate �, <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work he Fd( eF .. hi"application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Rla on of Sar <br /> Joaquin County Public Health Services. <br /> Job Address Ee. 14 0 V City Lot Size/Acreage <br /> Owner's Name_XTP-_ Address 71 <br /> 02 HOY (a d4dA Phare Cf <br /> TA�J Z6 <br /> ntr 1 � �a r �0, : 7 � �aKz <br /> o acro 00—Address ass {�,,,,,r <br /> .._.,_,.._ t?"� License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM 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 AREA CONSTRUCTION SPECIFICATIONS- <br /> , <br /> A <br /> C7 Industrial . ❑ Open Bottom ❑ Manteca Dia. of WeH Excavation clia. of Well Casing 1` <br /> n Domestic/Private Cl Gravel Pack 0 Tracy T.y-pe,.of..Casigge "cations (1' <br /> FI Public = 1-1 Other n Delta Depth of Grout Seat ut <br /> I i Irrigation _'Appro'x..Depth. I I Eastefn " Surface Seal Instalie , 1 <br /> Repair Work Done 0 Type of Pump H.P. S <br /> °�' <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth ler Material M Depth IU <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1. I EPA A601TION DESTRUCTION I I (No septics ittad if public sewer is <br /> available withinWYM.1 <br /> Installation will serve: Rest once commercial_ Other /� ! <br /> Number of living units: Number-of bedrooms f <br /> Character of soil to'a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments \ <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. 8 Length of lines Total length/size <br /> FILTER BED {1 Distance to nearest: Well <br /> ��`Fountlation ��•f Property Line <br /> SEEPAGE PITS Depth S Silo Number ' <br /> SUMPS LI Distance to nearest: Well ft's O �f Foundation�Jp Y­ Property Line <br /> DISPOSAL PONDS p <br /> l hereby certify that (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 Sen 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> c*rtifies the following:"I certify that in{he performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa• <br /> tion laws of California." <br /> The applicant call for all ad i pections . Complete drawing on ravetso side. <br /> Signed J ) qyt*A4 <br /> Title: Date: <br /> t FOR DEPARTMENT USE ONLY <br /> App cation Accepted by Date Area <br /> it r Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> a <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> �i Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE L� <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'NO. <br /> . EH 14,2 IR[Y.,i n so� /� l rJV !/ /�j` /1 <br /> EH 13.26 / ! <br />