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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468^-3447 <br /> ED <br /> 6, ERMIT FX 3AR PROM DAIS 1,9SU <br /> N _ (Complete is Triplicate) <br /> Application is hereby mad�a.n Joaquin County for a permit to construct and/or insSatall the vork herein ascribed. This <br /> application Se made in compliance with n Joaquin County Ordinance No. 549 and 1662 and the ltulea and Regulations or San <br /> Joaquin County Public Xsalth 9ery1ces. /W 94— <br /> Job Address —n f1 �A.,. City Lot Size/Acreage l�? <br /> Owner's Name k.1 m M If V"t b ty 0M?1 5 Address 1 t S �f let -P 7t7C1~ <br /> }} Phone <br /> t <br /> Contraclo� 1 Address Zst <br /> License N0,222.6-46 _ Phone �- 2- <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION CI Out of Service Wall ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 6djon;toring well [I <br /> DISTANCE TO NEAREST:_SEFTIC,TANK,1�_-SEWER LINES,�rSQ` !DISPOSAL-FLD.///14 PROP..LINE4�3oo��3``///�/ _ J <br /> FOUNDATION t1 AGRICULTURE WELL OTHER WELL— PITS/SUMPS/ < <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i7 Industrial ❑ Open Bottom. ❑ Manteca Dia, of Well Excavation 6, Dia. of Weil Casing r <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Dmf Specifications- <br /> Q Public Cl Other ❑ Delia Depth of Grout Seal f Type of Grout <br /> CJ lrriUation _110L.Approx, Depth ❑ Eastern Surface Soul Installed by- cfa✓ <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Dsstruction O Well Diameter "# Sealing Material i Depth <br /> Depth filler Material i Depth <br /> T E OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sawer is Vr , <br /> available within 200 fast.) <br /> Installs will serve: Residence— Commercial Other <br /> Number of live units: Number of bedrooms <br /> Character of sail to pili of 3 feet: Water table do <br /> SEPTIC TANK. ❑ /MfgI <br /> Capacity mpartments <br /> PKG. TREATMENT PLT, Cl : Method of Disposal <br /> Distance to rest: Well Founds ' Property Line PA MENT <br /> i RECEIVED A�s <br /> LEACHING LINE 0 No. & Length�of lines Total length/sire <br /> FILTER BED G Distance to n' Wel! Foundation Property Line <br /> t SAID JOA E IN COUNTY <br /> SEEPAGE PITS Depth I Sire Number PUBLIC HEALTH H SERVICES <br /> SUMPS - -'= LI--0iatanca to neared: VS/elf ^a-y Foursdation� " Properly f'i e iRONMEMAITTAMAA DIVIS�Q , <br /> DISP L PONDS ❑ --� <br /> i araby certify that I have prepared this application and that the work will be done in accordance with San Jo county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I conify.that in the'performance of the work for which this permit is issued, I shall not <br /> imploy any porion in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> cenifies the lollowing: "I canify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa• <br /> flon laws of California." <br /> The applics st c for quir' inspe, i s. Co lets drawing o averse Sid <br /> Signed <br /> Title: Date: 7 ` <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dote Area �'0' i <br /> Pit or Grout lcmapection by ' Date Final Inspection by _ Date a <br /> Additional Comments: <br /> s <br /> Applicant - Return alcol Sas to: t <br /> P SAN JOAG UIN COUNTY pUBtIC HEALTH 98RVIC8S <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN-JOAQUIN, P O BOX 2008, STOCKTON, CA 05201 <br /> EEE AMOUNT DUE f' AMOUNT REMITTED <br /> INP 1 /+ r�CASH RECEIVED By DATE PERMIT'NO. <br /> £H s3.71(REV.ira6i <br />