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APPLICATION FOR PERMIT IWAN: <br /> SAN JOAQUIN COUNTY PUBLIC BEALTH SERVICES �a , zo <br /> ENVIRONMENTAL IiTsALTH DIVISION 5-0 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PST E jItPSS 1 YEAR rHq.M DATA 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 to made in cosipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joequln County Public Health� S ry <br /> (Servi)ces. , \ <br /> Job Address (QJ • T'"` - City L 1!��J Lot Size/Acreage <br /> Owner's Name t -GMS "��r` S Address _ t'-_=" ' - Phone 2� 2 2' <br /> 91 <br /> /5/33 Niru .e�o�-i��� ��✓c• <br /> Contractor _Address _31rI�rnA:►+� �rA 9�8.�-License No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Llrl ,'_-_(�pnK ,,nSC N U <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE Ll }' <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> M Public I'1 Other O Delta Depth of Grout Seal Type of Grout NST!_:fd! , t. <br /> G IrriOation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> R*pair Work Done LJ Type of Pump H.P. State Work Done _ <br /> Well Destruction IN Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> t E OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted it public sewer Is W[ <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial ` Other ( n <br /> Number of living units: Number of bedrooms_ �J <br /> Character of toil to a depth of 3 feet: --_--Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation __ Property Line <br /> LEACHING LINE C1 No. b Length of lines _ Total length/size <br /> FILTER BED C) Distance to nearest: Well _ Foundation -, Property Line _ J <br /> SEEPAGE PITS 11 Depth _. Size Number <br /> SUMPS LI Distance to nearest: Well _ Foundation_..__ Property Line <br /> DISPOSAL PONDS ❑ _ <br /> I hereby certify that 1 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 /> rectifies 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 companss- <br /> tlon laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X"/1 ' �r _ Title: i_n.r✓;i°r,vpTg.•n 'il i,{'��� r�,l ,: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by IliX _ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: bulfb rI Rl- byaS �!' mum L- SE5-5,1 b <br /> Applicant - Return all copies 6: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALT} D VISION PQFMIT/SERVICES 1 <br /> N SAN JOAQUIN, ,P t) OX 2009,NST0CKTON, !CA.,95201 �95 7 <br /> + t <br /> FAMOUNT pUE` AM000 I EMITTIi0� K` �EIVE p� j PEq�i 0. A"t <br /> ,A INFOEE Tti'", ., � ri.,a <br /> .. Err 13-;+tnEV.iin6i <br /> Err e.Ie � vi <br />