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43UU <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> ' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> d HERMIT O P IRES 1 YEAR FROM 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 cosyrliance 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 9,? O 3 N A 0 n J n n i City Lot Size/Acreage C­ <br /> Job <br /> Name S.t e U e So i aAi Address b Clime Phone <br /> Contractor Uank GIeQQ, Inc Address 2024 E. Cha�z.te2 lJay License No. 3 715 60 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW WELLx®x WELL REPLACEMENT r.1DESTRUCTION ❑ Out ice well Q <br /> PUMP INSTALLATION ®x SYSTEM REPAIR O OTHER O ins well O <br /> DISTANCE TO NEAREST: SEPTIC TANK,(- 15 0 SEWER LINES DISPOSAL FLD. PROP. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a,_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial O Open Bottom O Manteca Dia. of Well Excavation I " Dia. of Welld1asing ,2n <br /> X,RP0omestic/Private 'EL-Gravel Pack El Tracy Type of Casing_ f c2,2 Specifications ` <br /> I.1 Public Cl Other n Delta Depth of Grout Seal I fi,�_ Type of Grout V J <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by (� <br /> Repair Work Done U Type of Pump SiiH.P.H.P. State Work Done _ <br /> Well Destruction Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth Z <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of loll to a depth of 3 fast: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments A <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED O 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 /> Horne owner or licensed agent's signature certifies the following: "1 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 applican t all r u' n . C m to drawing on reverse side. <br /> Sigma Title: _ILS 41,g.9,9, Ze Date: 2 pec-9z' <br /> FOR EWPARTMENT USE ONLY <br /> Application Accepted by Date ,Z Z.� Area O 2 <br /> Pit or rou Inspection by � Data inal Inspection by Date <br /> Addhlonal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I K RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH 3 <br /> _51N <br /> 24IREv.,,w5, wN 3 rb7c a---o ��• �L-i-9 z `l�-^ r <br />