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( APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROK 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 1s 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. <br /> Job Address ''® T .4 tt� X <br /> City_ Lot Site/Acreage <br /> Owner'* Name L�. ' a1_4p <br /> -rp Ie V Address ;�57© caw �^ Phone +� <br /> ContractorAddress �D t � Pt License No. Z.-W Phone Z `` •�' <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well �� <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES !_._� DISPOSAL FLD'�� PROP. LINE �� <br /> FOUNDATION .--- AGRICULTURE WELL OTHER WELL �— PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {1 <br /> 17.1 Industrial Open Bottom O Manteca Dia. of Well Excavation Dia. of Well ,Casing <br /> U Domestic/Private Gravel.Pack O Tracy Type of Casing Specilications <br /> M Public Cl Other O Delta Depth of Grout Seal Type of Grout <br /> X11"Irigation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type p H.P. State Work Done <br /> Well Destruction Oell Diameter Sealing k Depth <br /> Depth Filler fUterial 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) (� <br /> Installation will serve: Residence Commercial"-_ Other `y1 <br /> Number of living units: Number of bedrooms 4 <br /> Character of*oil to a depth of 3 feet: Water table depth lk <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Foundation Property Line <br /> LEACHING LINE CI No. & Length o nes Total length/size <br /> FILTER BED ❑ Distance t serest: Well Foundation Property line <br /> A <br /> SEEPAGE PITS 11 De Size Number <br /> SUMPS LI stance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I hav(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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The sppIic&%jkt4 call for all req ired ins omplete drawing on reverse side. <br /> Signed Date: <br /> FOR DEPARTMENT USE,ONLY <br /> Application Accepted by e Data jLp,—/Area <br /> Pit or Grout Inspection by Date Final Inspection by _TLS' ' Date 3 <br /> Additional Comments: Z12.4 t /A 9 L 0521 fDyIJ 1.dll — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 + <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERM17'NO. <br /> INFO //� CASH / `� <br /> . EH 13.24IREV.�iAS) 5( `1 \ 1 �' qI—b3 !3 LJ <br /> EH—2* C� / <br />