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.APPLICATION <br /> SAIN JOAQUIN COUNTY PUBLIC aEALTH SERVICES <br /> CNVIRONMENTAL aEALTH DIVISION <br /> 445 N SAN JOAQUIN , PHONE (209)46$-3420 <br /> P 0 BOX 2009 , STOCKTON, CA 95201 <br /> PERMIT =IRES 1 YEAR FROM DATE ISSUED " <br /> Complete in friplicatel <br /> Application 1a nereby made to San Joaquin Cz my 'cr _ permit -o construct anaior iretall the vorx herein aescriuea. `is <br /> :•ppiicatien Is made in cmVilance with San ',;aquin i:curty Lardi-ance No. -9 ana 1bb2 and, tr,e Hules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ...._ ... ji lr.• <br /> `. > . /;- ._.r -`,. i. _ ..._.;�:.�...� .,�,. �... age <br /> 400 Address <br /> a1 5 t <br /> Owner s Name Address :z ���� i�.�i..� ' Phoneme <br /> oriIraCIor.':... :':.' �'': ^'d(]re55.:3�• ✓,= i '! ;1' %✓ r t —Cense Na �' Phone <br /> TYPE OF WELL;PUMP NEW WELL WELL REPLACEMENT DESTRUCTION Li out of Service Well <br /> PUMP INSTALLATION SYSTEM REPAIR 7 OTHER. Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _y } <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial Open Bottom - Manteca D a of Well Excavation Dia. of Well Casing <br /> Domesuci Private Gravel Pack Tracy Tope of Casing. Specifications <br /> Public %`'"Bt#+erDelta � �;, Depth O! Grout Seal Type of Grout <br /> Ineljatign Approa. Depth .. .. <br /> astern Surface haul Instaltnd by <br /> /1'tpeir Work Done L� Type of Pump H P. State Work Done <br /> Well Destruction G Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i DESTRUCTION I 1 {No septic system pefm}/tteo-rt.public sewer is <br /> available within.2Q0'- eat;) <br /> Installation will serve: Residence _ Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feat: (Writer table,'Oepth <br /> SEPTIC TANK ❑ Type/Mfg Capacity �-No. CoCnpartmant> <br /> PKG, TREATMENT PLT. ❑ Methodsigf Oisibwal' <br /> Distance to nearest: W q Feundatlon Property tine <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/siza <br /> FILTER BED C7 Distance to nearest: Well <br /> pion Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> Number <br /> SUMPS l-I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ' <br /> I hereby cernty that I have prepared this application and that the work wit be done in accordance wish 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 the following: "I cartify 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." Contractors hiring or sub-contracting signature <br /> Certifies the following: •'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> rion laws of California." <br /> The applicant must call for all required Inspections. Complete drawing on joi�arse side. <br /> • e4 <br /> w...cu._.. Y ..rte `...1 <br /> Signed 7(,:t.r.ds-u,... � ! 3 ��� , tr �- "' Title- r -r.i�_„ >< t.. ��.,,�1,:. ,� Date: � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area d <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments' 2,1 <br /> ". <br /> rtpptic:ant - Heturn all copies to: San Joaquin '::aunty Public Health' Services <br /> Environmental Health Permit/Services C, <br /> -145 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED NFO SASH RECEIVED BY DATE f PERMI1 NO. <br /> EH 13-$4 MEV,iin5i <br /> EH 14.79 <br />