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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOB 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> D ���„7 PEBMIT EXPIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Acti, Lot Size/Acreage LcC <br /> Owner's Nartte ����-r .,,.5 f Address Phone <br /> t <br /> Contractor I`ll 'n Address P0 aD) L�� 4d/Y. License No.�9�3_�r Phone <br /> TYPE OF WELL/PUMP: KIEW WELL WELL REPLACEMENT O DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION Or SYSTEM REPAIR O _ OTHER O Monitoring`Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ab fid SEWER LINES DISPOSAL FLO._�_ PROP. LINE 4L <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS( r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS j <br /> Cl Industrial X Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack O Tracy Type of Casing C Specifications <br /> M Public Cl Daher p Delta Depth of Grout Seal 1190 Ty of Qrout 35 _Ps:rC� <br /> I f f� <br /> gation �o0.Approx. Depth ❑ Eastern Surface Seal Installed by14 <br /> 1 <br /> spair Work Done U Type of Pump _H,P. State Work Done_ <br /> Well Destruction D Wall Diameter Seal-iins Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 11 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 foot.) <br /> Installation will serve: Residence_ Commercial i Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size .►—� <br /> FILTER BED n 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 O <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 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 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must callforall required inspgctions. Complete drawing on reverse side. <br /> Signo4rj, A YV /�, s2 A A-4 ,&Z Title:e e e rt. <br /> Date: L Xpz 4q <br /> ARTMENT USE ONLY <br /> Application Accepted by .. ar- ,�,- �AData —a Area12, <br /> Pit orro Inspection by T!_- /'���_� Date _ Final Inspection byl. �L.�- sY Date _�?�1 <br /> Additional Comments: ✓��, � 0 rL //,.�,,, ,a 7- <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 MOUNT DUE AMOUNT REMITTED CI` RECEIVED BY DATE PERMIT NO. �?y� <br /> INFO 11_,r CASH a� <br /> . EN13INEV.rinsl I U lr� I-G�"E'y �t <br />