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�r <br /> ' APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 FROM DATE ISSUED <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 and Regulations of San <br /> Joaquin County Public Health ervices. rr <br /> Job Address Ei�f _ Gly_ Size/Acreage 1 _Lot Siz !v ��, <br /> Owner's Name � _ L Addres l.-.M• - Phone <br /> Y M' Contract Address License No Pho i <br /> TYPE OF WELL/PUMP:e NEW WELL C7- WELL REPLACEMENT C.1 DESTRUCTION ❑ Out of Service Nell O <br /> PUMP INSTALLATION O SYSTEM REPAIR C' 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 /> Cl Industrial _Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C Domestic/Private CI Gravel Pack O Tracy Type of Casing Specifications <br /> I'l Public f 1 Other 4 rl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth' ,I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ N <br /> l } \ Sealing Material i Depth I <br /> f Well Destruction, O Well Diameter I O <br /> r Depth 'Filler Material,& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITIONA DESTRUCTION fNo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation wdl serve: Residence.!L Commercial— Other INK <br /> Number of living units: __J_ Number of bedrooms <br /> f Character of sail too o1 depth of 3 feet: A Water table depth <br /> SEPTIC TANKNEW 'X Type/Mfg � � Capacity_ No. Compartments r <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Dist iance to nearest: Well _ Foundation /� Property Line 0 <br /> LEACHING LINE jEWST No. b Length of lines i f �Olal length/size <br /> FILTER BED _ n Distance to nearest: Well Foundationx Progeny Line <br /> SEEPAGE PITS 11 Depth 1 Sue 2,��_ Number <br /> SUMPS Lt ,/Distance to nearest: Well Fou7t'd lion-4 Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that I have prepared this application_ and that the work wilf be done in accordance with San Joaquin county ordinances, state laws, and <br /> { ruins and regulations of the San se Joaquin County ) of <br /> k � ? ' <br /> Home owner or licend agent's signalure certifies-the following: "I certify that in"he performance the work for which this permit is issued, I shall not <br /> /employ any person in such manner es to become subject to workman's comperi3ation laws of California.'Contractor's hiring or sub-contracting signature <br /> t certifies the following: 1 certify that in'the performance of the work for whicli this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant for all require in". ions.,Gomp1 a drawing-on reverse side. <br /> Signed Title:��' Date: r <br /> TMENT USE ONLY <br /> + Application Accepted jy ~r bate z-- Area 0LID <br /> Z <br /> Pit or Grout Inspection iby Date Final Inspection by Date� Y <br /> f IO'W <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services 1 <br /> i 445 N San Joaquin, P 0 Rox 2009, Stkn, CA 95201 <br /> } 1 <br /> t IFEE AMOUNT DUE AMOUNT REMITTED CASH FIECEIVED BY DATE PERMIT NO. <br /> / Q Q <br /> En 133a(ACV.rins) ` v Q 'r'� b /6�9-1 Z_ 7Lr Co <br /> EH 11.20 �J <br />