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-� APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> t (209) 468--3447 <br /> R ATE IS9= <br /> (Complete in Triplicate) <br /> Application is hereby ardde,ta San Joequin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services... GW 4�r� ,Flo <br /> City Lot Size/Acreage <br /> Job Address /f ,[f <br /> Address H <br /> /�9 vjl Phone <br /> Owner's Name <br /> s !'nJint A Address _353 -Ali. Lf n Cd I'J License No., 0 Z Phone <br /> Conlracla tTJOS <br /> p: NEW WELL WELL REPLACEMENT C-1 DESTRUCTION 0 Out of Service Well Cl <br /> TYPE OF WELL/PUM OTHER ❑ Monitoring Well C.1 , <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ D <br /> DISTANCE TO NEAREST: SEPTIC TANK �� <br /> SEWER LINES — DISPOSAL FLD. PROP, LINES <br /> FOUNDATION ._„_,_.�..- AGRICULTURE WELL OTHER WELL piTSlSUMPS ._ <br /> INTENDED USE T OF WELL pROBLEM AREA CONSTRUCTION SPECIFICATIONS t1 <br /> _ Dia. of Well Casing <br /> f,7 Indust,;al Open Bottpm O Manteca D'+a. of Well Excavation L <br /> Type of Casing Specifications <br /> �mestic4rivate ❑ Gravel Pack, O Tracy Type of Grout <br /> Public to Other I' t. ❑ Delta Depth of Grout Seal <br /> d ca5lrta� <br /> CJ Irrigation 3V/- A Vox, De iM Eastern Surlace Seal Installed by <br /> H p State Work Done <br /> Repair Work Done L7. Type of Pump 1 Material 6 Depth <br /> Sealing _ <br /> Well Destruction O Wel! Diameter Fiber Material i Depth <br /> Y Depth system <br /> a TYPE OF SEPTIC WORK: NEINSTALLATION❑ REPAIR/ADDITION-ODESTRUCTION G iNo Sbperwihin 200 feet.) if public sewer is <br /> Wet <br /> installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> }SEPTIC TANK O Type/Mfg ; Water table depth <br /> I Character of soil to a depth of 3 feet: <br /> li - Capacity_, No: Compartments <br /> i L-1 * Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance tri nearest: Well Foundation Property Line <br /> r. LEACHING LINE ❑ No. ii Length of lines �' Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line' <br /> DISPOSAL PONDS a <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 /> F rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature cenifies 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 subject 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 taws of California." <br /> The applicant mu call for r uired inspections. Complete drawing on reverse side, <br /> F Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY t <br /> Application Accepted by *�� <br /> Date 3 Area d l <br /> r X71 1�q2_ <br /> ' Date�,� Final inspection by Date <br /> I Pit rout nspection by R <br /> F <br /> Additional Comments: <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 /> JNJ <br /> AMOUNT DUE AMOUNT REMrTTED Ck ;tRECEIVED BY DATE PERMIT NCASH //EH t3-24IREV.iin5i �� ~` � ! /— 7.� - - - <br /> EH 14.m '� 9�2 �' <br />