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APPLICATION <br /> SAN JOAWUIN COUNTY PUBLIC HEAL <br /> ENVIRONMENTAL HEALTH DIASMA <br /> 445 N SAN JOAQUIN, PHONE (2M-105-34201 <br /> P O BOX 2009, STOCKTON, C1. Aff" <br /> PERMIT RXPIRES I YEAR FROM D 1FAft ED <br /> t� �✓� (Complete in Triplica e 6be,,,a® 7 b 3 <br /> Application In hereb,�made to San Joaquin County for a permit to construct an p,ILVt�l. nR••a�TC1T�;�C��Y��-Mi <br /> application 1e made in compliance with San Joaquin County Ordinance No. 549 a -,86P one <br /> Joaquin County Public ,Health Services. of San <br /> L t <br /> Job Address jxa�. G? � �f�L4 _ City Lot Size/Acreage <br /> -Ll4r <br /> rZ creage <br /> ZZOwner's Name Address J t Phone <br /> r <br /> Conlraclor 4i JZ C' ddress ' sic ftf�' �' License No. Phone <br /> TYPE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER L] Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SiUMPS _ <br /> p' C <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSK .F <br /> /] <br /> f 1; <br /> CI Industnei ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> f) Domestic/Private Cl Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> I"1 Public 1.1 Other Cl Della Depth of Grout Seal Type of Grout <br /> I Irrigalion __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump H.P. State Work Done <br /> Weil Destruction Q Well Diameter _ Sealing Material 6 Depth <br /> Depth Filler Material & Depth a\' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: _ E NT Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ Capacif 9' sig= No. Compartments <br /> PKG. TREATMENT PLT. C] a a" " <br /> Method of Disposal <br /> Distance to nearest: Well Foundation £ ' <br /> �a 06pCtty Line <br /> c <br /> LEACHING LINE Cl No. & Length of lines F'tJrC;, <br /> FILTER BED ppI' rt.' <br /> [ ] Distance to nearest: Well . Fou"��ppt�i7�'�41rSYl 'T , i?roktgr��k'Lyi M1l_-_ <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS I..I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> l hereby certity that I 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 San Joaquin County <br /> Home owner or licensed agent's signature certifies tit a 'Wing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such n r as to become sU a to,V%-orkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I iE at in the pe rm c iof Ae work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must ca q in c a plate drawing on reverse si e. <br /> —717 <br /> Signed X v Title: _ lL {/t % -i C�ff� Date: a �� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by M l _ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <"' Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> J -7 <br /> Eh 14 25 f•• 34 1 <br />