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- r <br /> 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 /> PERMIT EXPIRES 1 YE�RQId_DATE- ISSUED <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 coWliance with San Joaquin County Ordinance No. 51+4 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City7_724tt4 Lot Size/Acreage _ 6 � <br /> P[ Owner's Name D - Address I/, � ` . Pho � S �� <br /> �r 11 ne <br /> Conttactor D w r`�— Address _.._ _ _—License No.��_Phone <br /> YPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT CJ DESTRUCTION ❑ Out of Service Well D <br /> ' PUMP INSTALLATION-E; SYSTEM REP7 © OTHER 0 Monitoring well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A E CONST CTION SPECIFICATIONS <br /> Ll Industrial D Open Bottom O Manteca' Dia. Wall Excavation Dia. of Well Casing <br /> [1 Domestic/Private C1 Gravel Pack ❑ Tracy of Casing— Specifications <br /> I'I Public,,+ 1-1 Other F1 Delta a th of Grout Seal Type of Grout <br /> I I Irrigation, —.Approx. Depth I I Eastern Surfs Seal Installed by 1J" <br /> Repair Work Done 0 Type of Pump H.P State Work Done <br /> Well.Destruction O Well Diameter Ing Material th <br /> Depth Tiller Material & Depth <br /> TYPE; OF SEPTIC WORK: NEW iNSTALLATIO Filler <br /> n DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence�__ Commercial Other <br /> Number of Wng.units: Number of ooms 2 t <br /> Character of snit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK $ Type/Mfg Capacity db No. Compartments Z # <br /> PKG. TREATMENT'PLT. ❑ � �.- Method of Di sal `! <br /> Distance to nearest: Wel!�"" ' Foundation cy Property Line �� r <br /> LEACHING LINE Cl No. & Length of lines Q G 3 —26" Total length/site o2fb YJ <br /> FILTER BED ❑ Distance to rest: Well� Foundation - �� Property Line <br /> _µ <br /> SEEPAGE PITS 11 Depth Sixe r Number <br /> SUMPS LI Distance to nearest: Well Foundation: Property Line <br /> ISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done id 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*hall not <br /> employ any person in such manner as to become subject to'workman'i compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: I certify that in the performance of the work for which this <br /> " fy pe permit is issued, I shatl employ persons subject to workman's compensa- <br /> tion laws of alifw 1a" f <br /> The applica t mu L all If an required ins tk:rRS. Complete drawing on averse y 1 <br /> Signed Title: —� ` ..,._._,_— Date: _ 1`� y�� <br /> _ _ f EPARTMENT,USE ONLY i <br /> +� t <br /> Application Acceptedby- <br /> L_ y Cin Date Z----.Arse:0 I <br /> Y _ �y k <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: — 70 e..GC 1,.e',c <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Servicesp <br /> v. 445 N San Joaquin, P O Box 2609, Stkn, CA 95 O1 <br /> FEE <br /> L <br /> f/AMOUNT Dt1E AMOUNT REMITTED K CEiVEt3 BV ATE PERMIT-NO. //li /em t3.24IREV.frosti "� ^� `�7'� <br /> EH 14.26 // y <br />