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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> tPERMIT E%PIRES 1 YEAR tO1 DATE ISSUTD <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in ccupliance vith San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. n A <br /> 1 y �r� <br /> 9 Ll S S l,/S . oy-d- .3�. o QW 4"city_ G� Lot Size/Acreage ; <br /> Job Address -77 r <br /> Owner's Name,r�.�-V-6 A 11\4 �� t Address 3 O Phone f 1 r / <br /> P -QCk��, mil, A sz3 <br /> �r Contractor_ l�tv. Address License No. Phone <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ; <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private - ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications <br /> Q Public -1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> a Ifrivalion ­Approx. Depth ❑ Eastern Surface Seal Installed by �j I <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Wel! Diameter Sealing Material Z Depth C r, <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION.1=i DESTRUCTION I (No septic system permitted if public sewer is ; <br /> available within 200 feet.) L <br /> Installation will serve: Residence_,._. Commercial— Other <br /> Number of living units: )Number of bedrooms (1 ; <br /> Character of soil to a depth of 3 feet: Water table depth d <br /> SEPTIC TANK: ❑ Typa/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ �,t Method of DispoIs <br /> Distance to nearest. Weil Lit-�t� Foundation Property Line �a r <br /> LEACHING LINE L1 No. & Length of lines Total length/size 6 <br /> FILTER BED 171 Distance to nearest: Well Foundation Property Line , <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well ,Foundation Property Line 11) <br /> DISPOSAL PONDS ❑ O <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 <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 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 shell employ persons subject to workman's compensa- <br /> tion laws of Ca ifornia." <br /> The applicant U call requir cti�yi6. Complete drawing on reverse side(, <br /> >< <br /> _ <br /> Signed J11�� Title: . _�e.c'C._�.,3r .ant,�� Date: _ `2 -16—). <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by e Date /ylqp xArea a ' <br /> Pit or Grout Inspection by `= Date Final Inspection by Data <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 O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . tmt3.24rnt:v.,,nel �c�_oo �� eao a-� r.a • i3-st, <br /> ,. 1 <br />