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'■w <br />APPLICATION <br />1-2 u J <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San <br />€Lot Slze/AcreageCityJob Address <br />Phoneftrb -C- .* AddressOwner's Name <br />Contractor 1 <br />t <br />I <br />REPAIR/ADOITION <br />J , JTYPE OF SEPTIC WORK:to <br />Other <br /><7C> v c Capacity. <br />Foundation Distance to nearest:Well <br />3 i <br />FoundationWell <br />3 <br />vz <br />Date:Signed X.Title: <br />FOR DEPARTMENT USE ONLYI <br />Area DateApplication Accepted by <br />Date Pit or Grout Inspection by Fine! Inspection byDate <br />Applicant - Return all copies to: <br />i <br />T PERMIT NO.AMOUNT REMITTEDAMOUNT DUE DATE <br />o <br />I <br />I <br />f <br />Ifl____________ier.>ai-«.saas'aM3*rHi <br />No. & Length of lines <br />Distance to nearest: <br />LEACHING LINE <br />FILTER BED <br />FEE <br />INFO <br />Depth <br />Distance to neerest: <br />______Water table depth _ <br /> No. Compertments <br />Method of Disposal <br />Property Line <br />'I <br />> <br />1 <br />I. <br />■ <br />Additional Comments: <br />I <br />3^2^ <br />r to <br />- ss-j <br />li>Qr <br /> Number <br />/o' Property Line <br />Xi <br />In» <br />0 <br />O <br />I <br />i <br />I <br />3 <br />cn <br />Q.. EH tJ J4 (REV. i/»s> <br />EH IE-as <br />INTENDED USE <br /> Industrie! <br />Cl Domestic/Private <br />fl Public <br />I I Irrigation <br />Repair Work Done <br />Well Destruction <br />PERMIT EXPIRES 1 YEAR FROM DAT, <br />(Complete in Triplicate <br />c <br />{o<> <br />co0‘ <br />TYPE OF WELL <br /> Open Bottom <br /> Gravel Pack <br />Cl Other <br />Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />NEW INSTALLATION I I <br />Ro. anod <br />WELL REPLACEMENT O <br />SYSTEM REPAIR <br />. SEWER LINES DISPOSAL FLO. <br />. AGRICULTURE WELL OTHER WELL_ <br />Sealing Material A Depth <br />Filler Material A Depth <br />iUED <br />License No. Phone — <br />DESTRUCTION Out of Service Well <br />OTHER Monitoring Well q <br /> PROP. LINE . <br />PITS/SUMPS <br />PROBLEM AREA <br /> Manteca <br /> Tracy <br />D Delta <br />1 I Eastern <br /> H P. <br />SEEPAGE PITS <br />SUMPS LI <br />DISPOSAL PONDS <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 />rules and regulations of the San Joaquin County <br />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 subfect to workman's compensation laws of California." Contractor's 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 workmen's compensa­ <br />tion laws of California." <br />The applicentpu <br /> AJ <br />Installation will serve: Residence Commercial <br />Number of living units: Number of bedrooms <br />Chsracter of soil to e depth of 3 feet: <br />SEPTIC TANK "X Type/Mfg <br />PKG. TREATMENT PLT. <br />San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N. San Joaquin, P.O. Bor. 388, Stockton, CA 95201-0388 <br />__ Total length/size. <br />/ O Property Line <br />>ust call for>all required inspections. Complete drawing on reverse side. <br />Title: <br />CONSTRUCTION SPECIFICATIONS ’ ■ . ■ s <br />Dia. of Well Excavation ________ Dia. of Well Casing <br />Type of Casing ITA ------------------------- <br />Depth of Grout Seal PA I tWfeWsJciui <br />Suriace Seal Installed by ------RECEIVED------------ <br /> -------------> <br />SAN CO <br />destructToS < ww-' " <br />ass' <br />fe* 6^0 _ Address <br />TYPE OF WELL/PUMP: NEW WELL <br />PUMP INSTALLATION <br />DISTANCE TO NEAREST: SEPTIC TANK ----------------- <br />FOUNDATION <br />hV <br />oo^) <br />SAN JOAQUIN COUNTY PUBLIC HEALTH S. <br />ENVIRONMENTAL HEALTH DIVI l| <br />445 N SAN JOAQUIN, PHONE (209) 4( 9-- <br />P 0 BOX 388, STOCKTON, CA 95201 •( <br />Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br />^3oo € R.J <br />Sir. _____ <br />Well zrz>' Foundation