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N <br /> APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQU IN, PHONE (209)468-3420 k.T JV�6 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESP I RES IYE FR 1[ DATE IS UED, <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 sande in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PubAc Health.Services. COP? <br /> �_ �.... Lot Size/Acreage <br /> Job Address City <br /> e --7004 <br /> Owner's'Name <br /> 0, Q r Address 7-10 4ILy.-Jes Phone <br /> Contractor t� rfAddress ?45F� M IZTL1? License No- Phone ��� s- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 <br /> PUMP INSTALLATION U SYSTEM! REPAIR 0 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I �BD <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> �$�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W T5 <br /> Ll Industriai 0 Open Bottom ❑ Manteca Dia. of Well Excavation �1 <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f <br /> I'1 public f:1 Other fl Delta Depth of Grout Seal �TYW-O °ut f <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> &WZ5 --s- t' L— <br /> Repair Work Done U Type of Pump H.P. State Work Done �r <br /> Material A Depth <br /> Well Destruction O Well Diameter SeW`- <br /> Depth <br /> )Filler Material i Depth I rr� p6G <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms kc� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ .Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. A Length of lines Total length/size R <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ] Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 taws of California." Contractor's hiring of 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 applicant ust call for required inspections. Complete drawing on reverse side. <br /> Spm Title: E1�r6� 6OM3' Date: <br /> �Z63 <br /> YApplication Accepted by (Z4,,�XZ= Date A.. <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 O Boa 2009, Stkn, CA,95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED t3Y PATE PERMIT N0. <br /> INFO CASH <br /> • EH 11124 IREV,1/1151 Jf_] <br /> EH 1440 'ii lV <br />