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S <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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> ' Joaquin County Public Health Services. <br /> /',Job Address a �2 Ori-e --- City �`� Lot Size/Acreage <br /> kf <br /> )(Owner's Name e e Address 1 ys- '45, D Phone 62 <br /> /\ontractor DXQ r/e Ca Address d C,, el �a� License No.y�aZ J J Phone 33 y�� 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LOSAL FLD. PROP. LINE \ <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTI PECIFI CATIONS <br /> I-] Industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private El Gravel Pack E7 Tracy Type of Casing_ Specifications <br /> I'1 Public I-1 Other Cl a Depth of Grout Seal Type of Grout <br /> I I Irrigation __._Approx. l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth ille er al & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I i RE I I STr. ti s tem permitted if public sewer is <br /> it in 200 tast.l <br /> Installation will so": Residence_ Commercial�. � <br /> Number of living units: Qtk►p <br /> Number of bedrooms f'GGff �`have Wired without �y <br /> Character of sola to a depth of 3 feet:.. Olr baro t f'-C rppletnri pr ipen.ser table depth <br /> 1 <br /> SEPTIC TANK. O Type/Mfg wa v apace ��,,;;� a. ompartrrlants <br /> PKG. TREATMENT PLT.❑ E `� �LhiJiQQhod of Disposal <br /> Distance to nearest: Well Foundation . Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 certify that in the performance of the work for which this permit is issued, I shall -not'. <br /> employ any person in such manner as tas become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatuie <br /> certifies 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 CalifomWa <br /> The applies at II for all u inspections. Complete drawing on reverse side. <br /> Signed r Title: Q Date: <br /> FQ NT USE ONLY <br /> Application Accepted by —����te.s�AA \` T r Date `.Z L I Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> Eli14-2 IREV.lissi Ql3 � <br /> EH 1sa•ffi e�6z, - <br />