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APPLICATION FOR PERMIT wow <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 �V <br /> PFRiIIT MIRES 1 YEAR rR-09 DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to S"',Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in complianCa,with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address -� k11'5(,2A1, /A1 —. City S> � Lot Site/Acreage <br /> Owner'a Name 1WI-A m E S ddress E Phone 3_p -ga <br /> Contractor, 4)4WD Address W A 4-fl—f License No. 442-4 J-7G Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 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 GRICULTURE W OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL- Y PR-OBLE Oiiii. <br /> EA ONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottdm ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L) Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C Public i:l Other ❑ 0 a epth or Grout Seal Type of Grout <br /> 0 hripation __.Appro>,i,Depth Eastern Su ace Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ t <br /> I� Well Destruction O Well Diameter Sealing Materi i Depth <br /> Depth t. Filler Mlaterial i Depthry <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION Vf INo septic system permitted if public sewer is <br /> t _ available within 200 feet.) <br /> Installation will serve: Residencev' Commercial_A Other <br /> Numtiei oYiivinq units: ' ' Number of bedrooms '"' <br /> Character of soil to a depth of 3 loot: E Water table depth , <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r. _ -. .-,-- -._ -. Method of Disposal " <br /> Distance to nearest: Well Foundation Property Line <br /> k LEACHING LINE C1 No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> +'- SEEPAGE PITS 11 Depth f r Size 4 *Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 /> rutes 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 to becomeiubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <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 California." t <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed x_ `� Title: 4714 Date: <br /> i <br /> QR -ONLY <br /> Application Accepted byt Date Area l <br /> Pit or Grout Inspection by + Date Final Inspection by Date <br /> E Additional Comments. 3 _ <br /> Applicant - Return all copies to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> i � <br /> . EN 13.71 IREV,+iKbt <br /> f <br />