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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 Sea 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. 51+4 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ goo E City LAULot Size/Acreage + <br /> Owner's Name ��`�` y t ` Address ii�0_0 -9-1 y?fd n4 T Phone 3 b-7 '0-7 O <br /> Contractor Address _0!%L ( license No. . Phone ZZ <br /> TYPE OF WELL/PUMP: NEW WELL'"' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 <br /> t o <br /> DISTANCE TO NEAREST; SEPTIC TANK 00 'i- SEWER LINES­­P - DISPOSAL FLD. ,r-�: PROP. LINE -._ <br /> ""°�FOIyNt]AFEt�hf-= AGRIC-Ut�U-RE-WEi-N--z---� - GT-HIEfi-WEIL' PITSYSUM PS--J,'JP-V- <br /> INTENDED USE. '7YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T, 4 , <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Tr <br /> Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of CasingS-L+ Q Specifications rB <br /> Public (-7i Other 0 Delta Depth of Grout Seal 1Q`7Type of Grout <br /> 0 Irrigation ,i.._ Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done T f <br /> Welt Destruction ❑ Well'Diameter Sealing Material i Depth „F <br /> Depth Filler Material i Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION G 1No septic system permitted if public sewer is <br /> 1. 1 available within 200 loot.) <br /> r installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Clr racte gf.soil-to_a'aptt of 3 feet: r Water table depth <br /> SEPTIC TANK.�� ❑ ,Type/Mfg "`Caps lc yrc y No. Compartments } <br /> PKG. TREATMENT PLT.Cl F ,, Method of Disposal t . <br /> 10istance to nearer Wei ---- foundation Property Line <br /> _.' <br /> LEACHING LINE Q INo. & Length of lines _ —_ _ - Total length/size y <br /> FILTER BED '❑ 'Distance to nearest: ' Well-- - ation'7 Property Line .;r <br /> SEEPAGE PITS 11 Depth Number k <br /> . �. <br /> SUMPS LI Distance to neereSV-' 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 Sin Joaquin County <br /> Home owner or licensed agent-'s signature certifies the following�certity 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 foliowin : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman'sacompensa- <br /> tion laws of Califor a." <br /> The applicant m c -all rs fired�Sions, Complete drawing on reverse:fide, <br /> Signed Title: Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate Area <br /> Pit or Fal <br /> o Inspection by ate Final Inspection by Q� pate { I <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ._ <br /> ENVIRONMENTAL HEALTH DIVISION PSRMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNTrDUE AMOUNT REMiTfEO ,{[ASH ,[K 0 RECEIVED BY DATE PERMIT'N`O�. <br /> � EMt{2�41RELr.rin51 V L.Ov ������ C:��� ` i,ft Y ��Z_r� � { I—�� 3 � <br />