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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 0 BOX 2009, STOCKTON, CA 95201 <br /> i <br /> / <br /> PERMIT EXPIRES I Y FROM DATE ISSUED <br /> C� � . (Complete in Triplicate) <br /> Application in here made to San Jos uln C t for r <br /> ISP by q y 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 or San <br /> k Joaquin County Public Health Services. �n / d <br /> 1 Job Address � y! _/�[/ City (-J�l Lot Size/Acreage !0 A< <br /> � 1 ia � / z.v <br /> Owner's Name `L/lIr-i/ MA Address _ ���r! L Phone <br /> Contractor_ 44lfX (;aos's Address r ��� License No. :7 3p3 Phone 37�� <br /> TYPE Of WELL/PUMP: NEW WELL• WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIOnt�� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> <DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLS PITS/SUMPS v' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing D` <br /> aDomestic/Private ravel Pack ❑ Tracy Type T g_ Specifications ��vo� <br /> I of Casin <br /> 1 1'I Public EI Other n Delta Depth of Grout Saltoi> Type of Grout <br /> I I Irrigation `� Approx. Depth l I Eastern Surface Sed$ Install- Q,0— 77;;-A 7�1— <br /> Repair Work Done U Type of.'Pump. H.P. 1 e 1,C�l, <br /> State Work Done <br /> Well Destruction 0 Wall N imeter Sealing Material i Depth <br /> ' Depth <br /> Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION 1 11 DESTRUCTION I I INo septic system Perm$tled it public sewer is <br /> available within 200 lost,I <br /> Installation will some: Residence Commercial_,_. Other `. <br /> Number of living units: -'"Number of bedrooms _ '1 ^~ Z,� <br />! Character of loll to adepth of.3 feet: 1 Water table depth <br /> i SEPTIC TANK. ❑ T�Y /M1 ` t <br /> t- Pe 9 Capacity No. Compartments <br /> PKG, TREATMENT PLT.❑ Method of Dispose <br /> ;x. <br /> Distance to nearest: Well Foundation Property Lina, <br /> LEACHING LINE C1 No, fI Length of lines Total length/size t_i J y <br /> I FILTER BED ❑ .Distancs to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS 11 Depth <br /> Number <br /> SUMPS Distance to rwwostl:oil Foundation Property Line , <br /> DISPOSAL PONDS ❑ <br /> i <br /> 1 hereby certify that I have prepared this application-and-that"the Work will b-c d6ne-in accordance'1Nith-San Joaquin cotinty ordinances-state la -end <br /> rules and regulations of the Sjn Joaquin'County <br /> Homs owner or licensed agent's signature cenifies the following: "I certify tha'i.in,the performance of the work.for which this permit is issued, I sha <br /> employ an 1 g Pe g g <br /> A y person in such manner as to become subject to workman's compensation laws o}California:'�Coritractor'a Kirin or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Califcrnla." <br />€ The applicant must call for alllequired inspections. Complete drawing on reverse side. <br /> Signed Title: a C.v'.A-ICA? Date: 1--n—�3 <br /> k - , <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Data } <br /> � Area_ .1,. G <br /> Ph or Grout InspscWn by Date Final Inspection by bate <br /> Additional Comments: <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> l 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. <br /> INF <br /> + EM 17-14 11tEy.r/e S J a ! f <br /> Ek 1676 / ` <br />