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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED <br /> 1-4-v7- 61T-6-G19 (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 in made incompliance vith San Joaquin County Ordinance No.,- 49 and l ander�s and Regulations of San <br /> Joaqusa county Public Hem Services. ,� h r ++ <br /> Job Address R +' City �Q Lot Size/Acreage Q' I <br /> � Owner_s_Name__IILQdre s' S r A PhoneZ'g-0 � <br /> Contractor, ,J1 t h Address License Noar S� Phons3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT M• DESTRUCTION,Ci Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ <br /> Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES DISPOSAL FLD. PROP. LINE ZmfJ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS/ 257 <br /> INTENDEVUSE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS chi <br /> 0 Industrial 'Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Wall Casing <br /> )<Domestic/Private ❑ Gravel Pack Cl 7r0cy Type of Casing_ ee- Specification <br /> 1.1 Public I.3 9her fl Delta Depth of Grout Seal ® Typa_at_ out tri` <br /> I I Ir6gation �!2�.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump - H.P. State Work Done �g A-,, AO '- <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth <br /> # Depth Tiller Material i Depth { T <br />' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public seweir is <br /> available within 200 feet.) Y <br /> Installation will serve: Residence_ Commercial— Other V{ <br /> Number of living units: Number of bedrooms �. r <br /> Character o/aoq to a depth of 3 feet: Water table depth G <br /> I� SEPTIC TANK- O Type/Mfg - Cipacit -�� No. Compartments <br /> 1 y <br /> PKG. TREATMENT PLT.Cl i. � -- "- � - Mathod'of Disposal <br /> Distance to nearest: Well Foundation Property Line f <br />`. LEACHING LINE Ll No. S Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> y SEEPAGE PITS & I Depth Sire _ -- Number <br /> SUMPS LI Distance to nearest: Well Foundation�` Property Line 4a <br /> DISPOSAL PONDS ❑ f '" "` f <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 liws of California.•• Contractor's hiring or sub-contracting signature <br /> certifies the following:'9 cenify that in the performance of the work for which this permit is issued;I shall employ persons subject to workman's compen <br /> tion laws of California." f f <br /> The applicant must call r all rsquirad 'nspgctions�Complete drawing on reverse Sid?. <br /> Sig Q Title: ` '-�- Date: <br /> Application Accepted by Date Ar C> 42- <br /> Pit <br /> Pit orInspection by Date 43�� Final Inspection by Date <br /> 919 t <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County%Public Health Services <br /> £nvironmental'Health Permit/Services <br /> 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 <br /> i F <br /> s FEE AMOUNT DtlE AMOUNT REMITTED ' CA8if RECEIVED By DATE t-putiArrNOr- <br /> INFO <br /> ip 1'l.J (J J i ,��.w�.��EH t3"z4IREV.rr9eiW 1J;. wGz ,53 <br /> EH 14.1E <br />