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' .PPLICATION <br /> SAN JOAWUIN COUNTY PUBLIC HEALIF1 SERVI .._ <br /> ENVIRONMENTAL HEALTH DIV -7g rg __.. <br /> 445 N SAN JOAQUIN, PHONE (209 4 — 2U <br /> P 0 BOX 2009, STOCKTON, Cg <br /> ERMIT MIMS 1 YEAR FR M DNA N _�� -9 065 <br /> � <br /> (Complete in Triplicat <br /> Application is hereby made,t:o Sas Joaquin County for a permit to construct and/or install. the work herein described. This <br /> application is made in ccuplisnee with Ban Joaquin County Ordinance No. 549 and 1962 " the Rules and Regulations of San <br /> Joaquin County Public Eealth Services. <br /> 1 1 1 Lt City a`� !N/ Lot Sixe/Acre>ge %1C..�C -' <br /> Job Address 44 ! a L■� <br /> Owners Narrw <br /> I � _ Address <br /> Contrac o <br /> '! Addre r en No�� <br /> TYPE Of WELL/PUMP NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION U OTHER ❑ Monitoring Well ❑ <br /> SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL QLD. PROP_ LINE. <br /> FOUNDATION __ AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ID Open Elortom L Manteca Die. of Well Excavation. ois. of Well Casing <br /> 1.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> 11 Public V1 Other n Delta Depth of Grout Seel Typo o1 Grout <br /> I I Irrigation Approx. Depth S I Eastern Surface Seal Installed by 4 <br /> Repair Work Done L3 Type of Pump H.P. _ Stale Work Done_ <br /> Wall Destruction CJ Wall Diameter Seciir4g Material L Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADWTIi N �E57RUCTION I I tNo septic system permitted if public sower b <br /> available within 200"Iasi.) ^Tdw� <br /> Installation will serve: Residence Commercial_ Other "k <br /> Number of Living units: . Number of bedroom% _s�, ' � t <br /> Character of soil to a depth of 3 feet_ N MC72 a F_ Water table depth <br /> SEPTIC TANK 1Y� jx. Type/Mfg I_ Capacity — No. Compartments <br /> PIcG, TREATMENT PLT- 0 Method of Disposal <br /> LA <br /> Distance to nearest: Well y/�j Foundation s, Property Line l�r <br /> LEACHING LINE AJUS7T-0 No. & Length of lines _ Total length/site <br /> FILTER BED ❑ Distance to nearest_ Wed Founeation p— IMIE' 'i <br /> SEEPAGE PITS 0(-Jt-T1 I Depth Size N nm t l <br /> SUMPS LI Distance to nearest: vveu Foundation rd M4 <br /> DISPOSAL PONOS 0 `:l1-' R` ti <br /> I hereby certify that I have prepared this application and that the work will be done in a otftnt'a gAIpi SJW,jfz&$NQ�ty ordinances.state laws, and <br /> rules and regulations of the San Joaquin County ENVIKurgfR�-iN I n,nEALTH DIVISION <br /> Home owner or licensed apenCs signature certifies the following: "I certify that in the pariormance of the work toe which this permit is issued, I shall nol <br /> employ any person in such Wanner as to become subject to workman's compensation laws of California.-Contractors hiring or subcontracting signature <br /> esrtifies the following:"1 certify dial in the pertorntance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for�.il required leescoons, Co plate drawing on reverse side. <br /> Signed r' Title: � ��"� Date: . <br /> FOR DEPARTMENT USE ONLY <br /> App6catiorn Accented by Date Area rr <br /> PH or Grout Inspection by Date Final Inspection by ria Y 4 <br /> Additional Comments: <br /> W-7 1qq <br /> Applicant - Return all copies to: San Joaquin Cou'n'tT-15ubli& Health Services <br /> 1 s. <br /> Environmental Health Permit/Services A �� <br /> � "(�� 445 N San Joaquin, P O Box 2008, Stk <br /> ) a, CA 01 (� `fit <br /> W1+' INFO AMOUNT DUE AMOUNT REMITTED M ECEN Y PERM <br /> ell f7-24 IRrzv. i a, I& <br /> EN 14.E <br />