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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION SCANNED <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 /> 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 County Public Health Services. <br /> /SS"a S, "/3 S�' <br /> Job Address City STXx1 Lot Size/Acreage <br /> Owner's Name F F/EL P e Address 3-4-6- <br /> Phone <br /> Contractor 84-OW2 Af/"4r> Address 7 A4 owg, License No. .��-7b Phone 414-C-719 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �J11 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing (� <br /> fl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (Of DESTRUCTION I I (No Septic stem <br /> p y permitted it public sower is <br /> available within 200 lost.) <br /> Installation will serve: Residence_ Commercial_ Other X' <br /> Number of living units: Number of bedrooms A <br /> Character of soil to a depth of 3 feet: @"IV Water table depth II n <br /> SEPTIC TANK. O Type/Mfg la) Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. 6 Length of lines 1- 'fid <br /> Total length/size <br /> FILTER BED O Distance to nearest: Wall /s4L r Foundationzae�-► Property Line /00 1 <br /> SEEPAGE PITS I Depth 2-< / Size--J�y& 'i Number 7- <br /> SUMPS Ll Distance to nearest: Well Z&u, Foundation Property Line /©B't' <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 compenss- <br /> tion Iwo of California." <br /> The applicant must call <br /> for all required inspections. C plata drawing onreverseside. <br /> Signed X_ � _��_ r Title: (erste - <br /> Date: 1-2-9-9-4 <br /> v <br /> FORD ARTME USE ONLY <br /> Application Accepted by <br /> Date rea <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. <br /> INFO <br /> . EM 1124111tH.rinse S� / // / ^/ <br /> EH 14.M '^ � � 170 � D <br />