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tl <br /> APPLI CATIQNw.`"FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOK 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> -pa. vl."p PEMIT UPIRES, Y RISSUED OBOR 1) <br /> {Complete in Triplicate} U --O <br /> Application is hereby made;^to San Joaquin County for a permit to construct and/or install the work herein described. This j <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San JI <br /> Joaquin County Public Health Services. % IZ �� 11 p +3 <br /> Job Address >r F- <br /> A. � City r Lot gizelAcnAege <br /> � 2 <br /> AddressOwnar's Name rG Phone <br /> Gontracio 4 Address206,7C-4/C i -I License No.?.220 50.Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ;K OTHER 0 Monitoring Well G7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> r- Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> U Domestic/Private 0 Grayel Pack D Tracy Type of Casing Specifications t ' I <br /> M Public °.. f l Other 0 Delta Depth of Grout Seaf f ly Type of Grout t <br /> ylrrijfation�4)4 CV.Approx. Depth Eastern Surface Sed! Installed by <br /> Rspaif Work Done 'ice Type of Pump �.�. H.P. _ 15— _ - State Work Don <br /> Welt Destruction O Well Diameter Sealing Material i Depth 4 p' <br /> Oepth ' Filler Material A Depth <br /> TYPE OF SEPTIC WORK;` NEW INSTALLATION LD REPAIR YADDITION CI _DESTRUCTION M lNo septic system permitted if public sewer is `~ <br /> ` available within 200 feet.) 7 <br /> Installation will serve: Residence_ Commercial Other t <br /> Number of Jiving units:*, Number of bedrooms <br /> Character of coif to a depth of 3'feet: __ —Water table depth <br /> SEPTIC-TANK- M -�'❑ Type/Mfg _ l E' . Capetity #' No. Compartments <br /> PKG. TREATMENT PLT.:O li Me hod of Disposal <br /> DiMance.to nearest: Well Foundation Prgperty'Line <br /> I � ; <br /> t . . <br /> LEACHING LINE ❑ No. & Length of Imes -- Totaliength/size . <br /> FILTER BED n Distance to nearest; Welty Foundations` Property line <br /> SEEPAGE PITS I I Depth Size Number ­'".� <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0LI <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 I <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 become sublact to workman's compensation laws of California." Contractors hiring or subcontracting Sig 8ture <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I-shali employ persons subject to workm 's Co pensa• <br /> tion iaws of <br /> Th plicant mu call for ail re ins ions. Complete drawing o verse side. <br /> Signed Title: �� pate: <br /> �- PARTMENT USE ONLY <br /> Application Accepted by �`1�C�.A � Date'�3"� � Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVI&S--- <br /> r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX,2008, STOCMTON,,CA.', 5201FEE <br /> . s <br /> INFO CK 9 <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY � DATE 1 PERMIT'NO. <br /> + EN,3-Z41REV.I/" (s� 3.. l t. <{ \ <br /> C p <br /> EH 1{•2a l ��XC <br /> N <br />