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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> TNVIRONMENTAL' 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 /> I � a <br /> Application is hereby made,to San Joaquin 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 Cououmy Public Health Services. <br /> !I <br /> City i ae,(Ac r <br /> Job Address 4ilh �Q�!)5 !-loOeA «� <br /> Pfl- <br /> f! - Address w �WM4one — t <br /> Owner's Name <br /> � <br /> .M � License No. �Phone � <br /> Contractor Address <br /> Service tfel ❑ <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION Out of 1 <br /> 5Y57EM REPAIR © OTHE� Monitoring well <br /> ' © <br /> L7 <br /> PUMP INSTALLAT}ON <br /> J. <br /> DISTANCE TO,NEAREST: SEPTIC TANK ra - SEWER LINES.. DISPOSAL FLO.ike PROP. LINE <br /> �M FOUNDATION AGRICULTURE;WELL OTHER WELL PITS/SUMPS <br /> INTENDED.�USE TYPE OF WELL PR 8LEM AREA CONSTRUCTION SPECIFIC TI r� <br /> 717 <br /> ZWdustrial � ❑ Open 8onam Manteca Dia. of Well Excavatio Dia. of Well Casinamestic/Pnvate_;:� ravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I i<I (Olhor f-1 Delta Depth of Grout Seal Type of Grout['1 Publicl <br /> 6J <br /> I I Irrigation / pprox. Depth I I Eastern Surface Saul Installed by <br /> �Au n� <br /> Repair Work Done 0 Type of Pump — H.P. r State Work Done , <br /> Il' Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter [ <br /> 1 �h Depth biller Material i Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public.sewer is f`ill f <br /> p available within 200 feet.) V" <br /> Installation I I some. Residence- Commercial- Other <br /> Number of Hving units: Number of bedrooms „ <br /> Character ofh&A to a depth of 3 feet: Water table depth <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> j PKG. TREATMENT PLT.Ll Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> .-rte. <br /> LEACHING LIME ❑ No. b Length of lines II Total length/size ,V� <br /> FILTER BED ;`I 0 Distance to'nowest: Well 1IFoundation Property Line <br /> I. I <br /> SEEPAGE PITS i I Depth Size Number <br /> i <br /> SUMPS I LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 reg"tions of the San Joaquin County <br /> Home owneror licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the foibwing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Celifornla." ' <br /> The applicant I c for all requ'r "pions. Complete drawing on re se side. <br /> !I 4 � <br /> Signed Title: Date: <br /> IFOR DEPARTMENT USE ONLY <br /> t Application Accepted by Dass '" res <br /> Pito Grout spoctlon by Date ! Final Inspection Data <br /> i Additional Comments: <br /> Applicant - Return copies to: San Joaquin County Public Healt Services <br /> Environmental Health Permit/Services <br /> cel 445 N San Joaquini, P O Box 2009, Stkn, CA 95201 <br /> L11446 <br /> FEEFNT DUE AMOUNT REMlTTEO CK H RECEIVED BY O TE PERfiAIT'NO. n <br /> ry oa 1176 9 EN 1}21IItEV.1/�4! U L � / .. <br /> EN 14.2a <br />