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APPLICATION l 3 '-f 14 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> 5NV I RONYENTAL HEALTH DI V I O d 7 a3 <br /> 445 N SAN JOAQUIN, PHONE (209) 6 -�-- <br /> Fa <br /> P 0 BOX 2009, STOCKTON, CA 54Qb !„ <br /> II <br /> PERMIT EXPIRESYEAR R <br /> (Complete in Triplicate <br /> Application in hereby made.t4 San Joaquin County for a permit to construct and/o 1 e work bereir c bed. This <br /> application Is amde in Compliance with San Joaquin County Ordinance No. 549 and .8ryiea..as�-iia <br /> of Starr— <br /> Joaquin County Puutliic(�H(ealth Services. <br /> Job Address � aa) 4"Wil, _ Crty Vf I(I)Lott Size/Acrergc <br /> Owner's Name ^ �ddress --- <br /> Contractor - ��7 �- __ Address ?6�-of License noss2al Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ci DESTRJCTION l Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well U <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 /> n tndusinal O Open Bottom u Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> [I Domestic/Private U Gravel Pack 17 Tracy Type of Casing .__ _ Spec,hcations <br /> I'I Public fl Other i1 Delta Depth of Grout Sea! Type of Grout <br /> t I rrrrgatton __ Approx. Depth ; I Eastern Surlace Seal Instid iod by <br /> Repair Work Done 0 Type of Pump li P. State Work Done <br /> Wall Destruction O Well Diameter Sealing Material i Depth <br /> Depth Tiller Metrial i Depth J'S <br /> TYPE OF SEPTIC WORK. NEW INSTALLATIONREPAIR:ADDITION i i DESTRUCTION I I INo sepuc system permitted if public sewer is J <br /> available within 200 feei.l .C, <br /> Installation will serve: Residence-X Commercial_ Ot#ter <br /> Number of living units: _ /L Number otb*drooms <br /> Character of soil to a t of 3 feet: �' -1reyi Water table depth <br /> SEPTIC TANK Type/Mfg �'Nl�`S Capacity / No. Compartments �( <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal N <br /> Distance to nearest. Well Foundation w:�s 7t Property Line l0 <br /> LEACHING LINE No. b Length of lines Total length/si:• <br /> FILTER BED Q Distance to nearest: Well Foundation .�S/ '� Property Line <br /> SEEPAGE PITS I I Depth —._ Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation ProNmy Line A <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 centfies the following. "I certify that in the perlormance of the work 107 which this permit is issued, I shall not <br /> employany per such"nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cartil the f ng. "I comity{V the performance of the work for which this pwrntt is issued, I shall employ persons subject to workman's compensa- <br /> tion laws o sfittxnis <br /> The appli t must I or ,N r uired ins tan . om a drawing on reverse side. <br /> n <br /> Signed f FlLdVWX Title: Date: _ <br /> FOR DEPARTMENT US ONLY <br /> Application Accagtad by pare Arts s <br /> Pit or Grout Irtepectlon by , (� {� -Date Final Inspection by 'Dale�� <br /> Additional Comments: C-I- � 'w-J(Az� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services /�oOV IoW <br /> Environmental Health Perish/Services <br /> 445 N San Joaquin, P O Aon 2009, Stkn, CA 9520 <br /> INEFE� AMOUNT DUE AMOUNT REMITTED CK SCASH RECEIVED BY DATE PERMIT N0, <br /> t:H r4s <br />