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APPLICATION FOR PERMIT <br /> �FJ <br /> J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES; �`. ;r`,bl — <br /> ENVIRONMENTAL HEALTH DIVISION Nov 15 MO <br /> P 0 BOX 2009, STMKTON, CA 95201 J_L <br /> (209) 468-3447 IENVIRONMENTAL-, iv-ALTI! I <br /> PERMIJT/SERVICES <br /> I? pEUI3: EXPIgga I <br /> YEAR ROM DATE Iq-",URn <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sab 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 Services. <br /> 4��.Z Lot Size/Acreage <br /> Job Address-7_ city-LLA&,_� <br /> 4 <br /> Owner's Name Address Phone <br /> 7)ZA:�.�_�� <br /> Address <br /> Contra <br /> Cto I MAE AAA/, i c e n s e N o. Phone <br /> 12 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 171 DESTRUCTION 0 out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f OTHER--WELL=L_t�- PITS/SVMPS—�--"� <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> V,industrial Cl Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Pack L) Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specification <br /> *ublic Cl other C1 Delia Depth of Grout Seal Type of Grout <br /> cjArfioation Approx" Depth 0 Eastern irface Seal Installed by 4) <br /> Repair Work Done Type of Pump`- H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/A0OITION 0 DESTRUCTION 1:1 (No septic system permitted if public sewer is <br /> available within 200 loot.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of ll�viriq units: — Number of bedrooms <br /> "Character'of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK, 0 Type/Mfg Capacity No. Compartments. <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well 'Foundalion— Property Line <br /> LEACHING LINE L No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest., Well t Foundation'r Property Line <br /> '«A <br /> k <br /> SEEPAGE PITS 11 Depth Sire N6mber <br /> SUMPS Li Distance to nearest Well Foundation Property Line <br /> —DISPOSAL-PONDS v El ri -. �.—'� A <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 I <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,-becomb compohsaiion laws-of r California:"-Contractor's-hiring-of sub-contracting-signature. <br /> certifies the following: "I certify that in 14performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 4r <br /> The applicant must call lor/ 11 required ins tions. Complete drawing on reverse side' <br /> Signed X Title: Data: 11-7 `70 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 2 <br /> Pit or Grout Inspection by Date Final Inspection by Date_47 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUkE , AMOUNT REMIT- 'CASH TED — CK RECEIVED BY DATE PFRMI7'N?J <br /> "'"J !�� I q0 <br /> EM 13•24 10MV,1/K 61 <br /> EH Z4I ,6 <br />