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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA95201 <br /> (209) 468-3447 MAR <br /> PMIT EXPIRES I YEAR PROM DALE I.,r.,ENV1 RON Mi ENTAL HEALT[� <br /> (Complete in Triplicate) PERMff/SF <br /> Application'LB hereby made.to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coWliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Ga <br /> Job Address 1,9-q42,2 L�O2 <br /> i t Size/Acreage <br /> ZIAZ-1- <br /> f\ owner's Namit qLC_C__z—Address Phone "Afl— <br /> /C Wna c I Mot Y, <br /> TYPE OF WELL/PUMP: NEW WELL Eli WELL REPLACEMENT F/ <br /> DESTRUCTION 0 Out of Service Well <br /> PUMP IN!ffALLATI04-Et�' SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES 61SPOSAL FLD._ PROP. LINE <br /> UND AT'0N----AGRIGUVT-U R E-WEL-L-T-_—,OTHE R-WEL-t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (71 Industrial 0 Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> P..5z4—Wnsstic1 Private 0 Gravel Pack 0—Tracy—=- Tlype-of-Casing�� Specifications <br /> M Public (1 Other 0 Delta Depth of Grout Seal 4 Type of Grout <br /> 0 Irrioation _Approx. Depth 0 ce_sealji3stallad-by <br /> Repair Work Done LJ Type of Pump H.P. late W one,!�,. <br /> Well Destruction 0 Well Diamete. Sealing Material & Depth <br /> Depth C11T�_i Filler Material & Depth <br /> -------------- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L7— DESTRUCTION El (No septic system permitted if public ifewer is <br /> available within 200 feet.) <br /> Installation will serve; Residence Commercial Other <br /> Number of living units: — Number of bedrooms <br /> yChatactof of Boit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg <br /> 4:Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method'of Disposal <br /> Distance to nearest: Well _1Foundation—..'" F Property Line <br /> LEACHING LINE C1 No. & Length of lines _"_T6:ta1-1ength/size <br /> FILTER BED n Distance to nearest., Wellr Foundation— Property Line <br /> SEEPAGE PITS I I Depth Siro Number .` <br /> SUMPS <br /> Ll Distance to nearest; Well Foundation f Property Line <br /> LOISPOSA-L-PONDS <br /> I hereby canitv that I have prepared this application and that the work will-be-do'ne in accordance with-San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county t,­om_ .1_.` . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performince 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 cornpensalion_lawi of California," Contractor's hiring or sub-contracting signature r\ <br /> certifies the following; "I certify that in the performance of.-th.o work for which.this-6e_rmit is issued, I shall employ persons subject to workman's compensa- 01` <br /> tion laws of California." <br /> The applica at te for �ad ed coons. Complete drawing on revs <br /> As side'. <br /> Sign� Title Date: rvL7191 <br /> T USE ONLY <br /> Application Accepted by Date 3-1 -17/ -- Area <br /> Pit or Grout Inspection by, Date Final Inspection by:T;422?a::�4 a,-,9_ Date <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 OiBOX 2009, STUCKTON, CA 95201 <br /> VCK <br /> FEE AMOUNT DUE AMOUNT REMITTED RICEiVED BY DATE PERMIT NO. <br /> INFO CA$H <br /> • <br /> H H u113.2/ <br /> 24 4AEV. 5f <br />