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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALT 9%#CES +� <br /> ENVIRONMENTAL HEALTH DIVII*N40 <br /> 445 N SAN JOAQUIN, PHONE (209)P O BO% 2009, STOCKTON, CA <br /> PERMIT EXPIRES I U!,AR FROM ]DATE - <br /> (Complete in Triplicate INV # O <br /> Application Ss hereby made_to San Joaquin County for a permit to construct andJona a vvrere n escr e 1{hls -� <br /> application is made in cotipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Be vices. <br /> Job Address �' _1 � C-ty _L_q+� Lot Size/Acrev.ge / C, <br /> Owner's Name t= u r�'` Address Phone `'�'� �4 <br /> Contractor "' Address _ License No,,36�-/ Phone h�'3133 <br /> TYPE OF WELL/PUMP: NEW WELL 7 WELL REPLACEMENTi: DESTRUCTION Cl out or Service Well C) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR F, OTHER 7 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _.__ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom C Manteca Die. of Well Excavation_ Dia. of Well Casing <br /> [.i Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing___.. Specifications <br /> Il Public (-1 Other I ) Delta Depth of Grout Seal T_ Type of Groul <br /> 1 Irrivation _Approx. Depth 11 Easter, Surface Soul Installed by <br /> Repair Work Done [' Type of Pump H.P. - State Work Done, <br /> Well Destruction ❑ Well Diametar selling Material i Depth �D <br /> Depth Piller Material 7, Depth <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION li REPAIR/ADDITION I : DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence V Commercial— Other <br /> Number of living units:!i Number of bedrooms (-\l <br /> 1 <br /> Character of soil to a depth of 3}set: - Water tebM depth ,2 S <br /> SEPTIC TANK tll Type/Mfg _ Capacity_ �"r! No. Compartments 2 <br /> PKG. TREATMENT PLT. 0 _ t Method of�DiIS"I <br /> Distance to nearest: Well.1 6b ,— Foundation�3S Property Line _ <br /> LEACHING LINE Length of lines _�� �- rD Total length/site � r <br /> FILTER BED O Distance to nearest: Wall 130 � Four,aavon _ �p , _ Property Line � r <br /> SEEPAGE PITS I I Depth __,.._ .Si:e TM - _ Number <br /> SUMPS t;l Distance to r4wisst: Well Foundation Pr"rty Lire <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin County <br /> Home owner a Licensed agent's signature ceriph"the lollowing; 'V 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 /> candies the following: "I certify that in the performance of the work for which Ihis permit is issued,I shall employ peraci subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for ail It rred i pections. Complete drawing on reverse side. <br /> r <br /> Signed X^I Title: __ at. -c&C Date: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accented by Date i ah I Arse_ - <br /> Pit or Grout Ittapection by Date Finial Inspection by Date <br /> Additions! Comments: <br /> Arpiicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Eealth Permit/Service", <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA HS!DATE <br /> tcC�'1✓J[] <br /> INCK III <br /> E AMOUNT CUE AMOUNT REMITTED CASH RECEIVED BY <br /> H 32.OIEV.�ixei - �� Iti 9� Y3 -Lb <br />