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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 9Z-OQ 23 <br /> 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules end Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City 44 Lot Size/Acreage <br /> Owner's Name Address 1/ "�'r"� — Phone <br /> Contractor Address & i f w&51 (A License NoVII Phone <br /> TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT C:} DESTRUCTION ❑ Out ofiService Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHEtbQ---, Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. �� PROOP. LINE M <br /> }..:.�.r.�__, .. FOUNDATION � AGRICULTURE Llh� L — OTHER WE � PITS/SUM <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF CATl`ONS '—'---'1L <br /> i <br /> } C1 Industrialpen f3ottpm 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> Cl Domestic/Private ❑ Gravel Pack L) Tracy Type of Casing_ Specifications{ <br /> Il Public Ia Other n Delia Depth of Grout Seal Type of Grout <br /> l.i*trngation _.Approx. Depth I I Eastern Surface Saul Installed by <br /> � Repair Work Done U Type of Pump H.P. _�— State Work Done <br /> Well Destruction D Well Diameter Sealing Material & Depth <br /> } �7 CA Depth Filler Material & Depth <br /> f TYPE OF SEPTIC W RK: NEW INSTALLATION i I REPAIRIADDITION 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 t <br /> t Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ;- �� achy No. Compartments f <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ t sP <br /> t Distance to nearest: Well Foundation Property Line *� <br /> i <br /> ' I <br /> # LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to near Well Foundation'" ... —. Property Line 4, <br /> SEEPAGE PITS I I �Ioepth Size NumberSUMPS Ll nearest: Well Foundation Property Line 1 <br /> DISPOSAL PONDS <br /> I hereby cenify that l e 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 /> i Home owner or licensed agent's signature certifies the following: "I 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 /> certifres the following:"I certify that in the performance of the work for which this permit is issued,'I shall employ persons subject.taworkman's compensa- <br /> tion laws of California." <br /> f}( The applica st C I uired i tions. Complete drawing on re ree side. i <br /> Signed Title: Date: p <br /> r ��3 <br /> F DEPARTMENT,USE ONLY <br /> '��v�- t 3 �- <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by:Z -20- �� Date ,1 <br /> Additional Comments:_ ` ¢ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental,Health Permit/Services ` <br /> . —1445'N San"Joaquin; 'P?D Box 2009, Stkn, CA 95201 <br /> FEE# INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATES /�PERMIT'N0. <br /> . E13.14(AEw.rips) W R �q ¢LrJ� V , t7�i ['�7 f-� 13-3`-"> 2N 1 3-v <br /> EHN t14-N � <br />