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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION lJ 7 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR 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 Services ] ,(�,1 7-MCF <br /> � �C [}�' /� <br /> Job Address -�5/ry�/-1/-���/7''/(� C�//P�.��/i V'1�� /� City -/ �j/) Lot Size/AcreageQ/" L�.7�� 7y N <br /> Owner's Name ���A,iI Rd`R660 „/�� ddrepu�� n��C//� �y��C/7� /O L�� Phone`'�`- 393-/sMO VOA <br /> Contractor RIVAL t��1 �a <br /> Address f(/ BtX �C/rJ ✓2 License No. Phone-x-" <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Yell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Rl'' Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. CINEB_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C Domestic"Private ❑ Gravel Pack C Tracy Type of Casing_ Specifications <br /> I'l Public 17 Other n Delta Depth of Grout Seal in Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Sudsce Soul Installed by 7 <br /> Repair Work Done C Type of Pump H.P. State Work Done <br /> Wail Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if pu lic w sr is <br /> available within feet n <br /> Installation will serve: Residence _ Commercial_ Other 7u, <br /> Number of living units: _ Number of bedrooms + J <br /> Character of wil to a depth of 3 fast: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmen <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. i Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nestsst: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cartify 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 /> Horth 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu <br /> tion laws of Cal ifornis." <br /> The applicant ca r quired inspections. Complete drawing on revs se side. <br /> Signed X Title: G 4 Date: <br /> TMENT SE ONLY <br /> Applicati 1 <br /> sptad by Date S / r Area ��� 7q p <br /> Pit or Grout Inspection by -� ��/JJ,�,// Date //-7-- , <br /> // — Final Inspection by Date <br /> Additional Commentss ZZ,& OC.svI '(1V.CJ�" <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEINFO AMOUNT OtlE AMOUNT REMITTED C- H RECEIVED BY rDATE /pP'ERMIT'NOD <br /> IaEV.iin al'f/ <br /> EM 14 V / <br />