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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COWTY 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 _SPIRES I YEAR FROM DATE IZSMEp <br /> _ (Complete in Triplicate) +� <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or in tell the Work herein described. This <br /> application is made in compliance with San Joaquin County Crdinance No. 549;and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address r City Lot Size/Acreage' ✓r <br /> T _ �� <br /> Owner's Name �1 0 _�t J G eh Address 3 Y � Y <br /> � _._ Phone <br /> Contractor 6L-k 644 e-k— Address License No. � Phone <br /> TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL :f OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATlO1NS <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' <br /> Dia. of Weil Casing <br /> fl Domestic/Private ❑ Gravel Pack ❑ Trac y Type of Casing_ Specifications <br /> i'1 Public 1-1 Other 1-1 Delta Depth of Grout SealType of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by J <br /> Repair Work Done U Type of Pump H.P. State_Work Done w <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No_seplicsyatem permitted if public sewer is <br /> .- available within 200 feet.) <br /> 4 Installation will serve: Residence Commercial_ Other <br /> Number of living units; T/_ Number of bedroo s e ek kV'cq <br /> Character of loll to a depth of 3 feat: -S baa ter table depth e � rC . <br /> SEPTIC TANK type/Mfg Capacity ' No. Compartments \� <br /> PKG. TREATMENT PLT.❑ Method of Disposal int <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 8 Length of lines Total length/size R <br /> FILTER BED O Distance to nearest; Well Foundation `' ro <br /> P pent/ Line <br /> SEEPAGE PITS 11 Depth �Gd-- Size Number /{ <br /> SUMPS ll Distance to newest; Wall Foundation �J <br /> DISPOSAL PONDS Cl <br /> Property Line <br /> 1 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 5 <br /> rules and regulations of the San Joaquin County <br /> Horns owner or licensed agent's signature certifies the following: "I certify that ih"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 /> eartifies 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required in coons. Complete drawing on reverse side. <br /> Signed Title: esM C{v <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area ^-- <br /> Pit or Grout Inspection by <br /> Data Final inspection by <br /> Date <br /> Additional Comments.- <br /> ,-Applicant <br /> omments:,.Applicant - Return all copies to: San Joaquin County Public health Services <br /> Environmental health Permit/Services <br /> 445 N San Joaquin, P O Box 2000, Stkn, CA 95201 i <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO CASH RECEIVED BY DATE PERMIT-NO. <br /> • EH 1524 WIV.1/K 51 <br /> EH 14-at <br />