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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC .HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> , P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--344-73q,2-0 <br /> k=IT UP199a I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to constructand/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 end Regulations of San <br /> Joaquin County Public health Services. <br /> Job Address-- -- [ -Ol � B LLC]t41ty l Lot Size/Acreage <br /> Owner's Name Address � 113.30 S- DGfIO �� <br /> phone <br /> i <br /> 7`C�nIi82Z;srr•�� _/J"i� - Addresers e-No.-.404S,39 Phone-- - - s <br /> ;TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> ti PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> 7DISTANCE TO NEAREST: SEPTIC TANK ___ SEWER LINES "'" DISPOSAL FLO, PROP, LINE F <br /> FOUNDATION ""f AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing y <br /> ,'U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications_ ." r U) <br /> k R Public F1 Other ❑ Delta Depth of Grout.Seal Type of Grout <br /> I CI Iffioalion Approx. Depth Q Eastern Surface Seal Installed by Q <br /> ' t Repair Work Done U Type of Pump H.P. State Work Done_�� <br /> f Well Destruction ❑ Weil Diameter Sealing Material i Depth V, <br /> Depth Filler Mat'erialrl Depth <br /> TYPE OF SEPTIC WORK: NEWANSTALLATION JO REPAIR-l:ADDITION 9L--B?5TAUCTION GI.IN a-septic•sysfern permitted if public stiwer is # <br /> v: available within 200 feet) <br /> Installation will serve: Reside_nce,=_o mercial Other____ :7�1. <br /> Number of living unite: "� Number of bedms <br /> roo #' <br /> i Character of soil to a depth of 3 feet: _ Water table depth " <br /> ,SEPTIC TANK ❑ Type/Mig _ I. Capacity No.rCompartments <br /> "PKG. TREATMENT PLT. 0 _ Method cf Disposal <br /> a.; Distance to near Well Fo ndstion• Property Line <br /> iLEACHING LINE t $ Length of lines _ Totai la6gth/size Ir <br /> IFILTER BED �_Llstanca la nearest: 0. Well Fou tion C,Property Line a <br /> SEEPAGE PITS I I Depth Size Number t s <br /> SUMPS LI Distance to nearest: Well foundation Property Line ' s <br /> DISPOSAL PONDS ❑ <br /> i I hereby certify that I have prepared this application and that the work,will-be done-in.accordance,yv_ith.San Joaquin county ordinances, state laws;and <br /> rules and regulations of the San Joaquin County <br /> Home owner of licensed ' <br /> a ents signature certifies the followin t <br /> g 9 g: "I certify that in the performance of the work for which this permit is issued, i shsll'not <br /> employ any person in such manner as to become subject to workman's compensatidn.:laws of Califomia." Contractors 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 compansa- <br /> tio la f Gallfornia: -s A= a <br /> Th eppficant call or ell eq led clions. p to dr ing on verse si e. <br /> Signed ' Date: <br /> "T"�"" TMENT USE ONLY <br /> Application Accepted by Date 2 Area, f <br /> Pit or,Grout Inspection by ==t Date Final Inspection by Date .2�&-7 { <br /> Additional-Comments: r<✓. r <br /> Applicant - Return all coPpies'-to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> ``445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT D AMOUkT REM3TTED CASH FIECEEVED BY DATE PERMIT'NO, <br /> . EH 1`'724 �� / 1�' � 7�D-7 <br /> � l lT1 <br />