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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> PERMIT EXPIRES 1. YEAR FROM DATE ISSUE <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 (rade in coWliance r►ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address -JQ Lot Size/Acreage 6-6/2 <br /> QG <br /> Owner's Name -00 QL Address /A3 2,5- LA GAD""A- CeL7`aJ Phone <br /> _ gz32-Y r <br /> Contractor 1 S Address 2525 �H C� G1 LJ-r___ License No. `tt3 __Phone - <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION P Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE G <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dis. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> (A Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I,Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U y Type of Pump H.P. State Work Done w ; <br /> Well Destruction Well Diameter _ _ sealing Naterial i Depth - !. <br /> Depth Filler Naterial fr Depth uStl�- OWt <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is `J <br /> available within 200 feet.) C <br /> Installation will serve: Residence_ Commercial_ Other <br /> I <br /> Number of Irving units. Number o1 bedrooms 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PL7.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line o <br /> {C <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll .Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 certity 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 /> candies the folowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California,,, <br /> The applicant must call for ail required inspections. Complete drawing on reverse side. <br /> Signed Title: � Sic�l s,- Date: -7 S <br /> FQFt DEPARTMENT USE ONLY <br /> Application Accepted by d i Date <br /> Pit or Grout inspaction by Date Final Inspection by ate <br /> Additional Comments: II !! <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, O-Box 2009, Stkn, CA 95201 <br /> IFEE AMOUNT DUE AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT-NO. <br /> . EM 1Y2411tEV.r/a$) GjD- &0- <br /> EH 14.20 <br />