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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 /> i. R <br /> `y (Complete in Triplicate) <br /> 11S '�tgo <br /> Application e feky made to San Jaaq is County for n permit to construct and/or install the work herein described. This ;l <br /> application isa Stade 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 /> Jab Addmp_ �,[, 5 City S7Q Lot Size/Acreage �� S <br /> ress ' C' A ..A <br /> Owner's Name Address [ C Phone-0: <br /> 1 !A E d _�r ZZ�P Phone — �1 <br /> Contractor .� Address License Na, <br /> TYPE OF WELLIPUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of—Service well 0 <br /> ❑ OTHER Monitoring'Well [.ISYSTEM REPAIR <br /> PUMA INSTALLATION ❑ Tt 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL FLID <br /> FOUNDATION AGRICULTURE WELL OTHER WELL P --- �j It (}i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS is.AZO r li <br /> n Industrial ❑ Open Bottom ❑ Manteca ri Dia. of Well Casing <br /> -Cl Domestic I Private ❑ Gravel Pack ❑ Tracy Tie-ek aain9 Specifications <br /> CI Public 1.1 Other ❑ Delta l7e <br /> Type I Grout � <br /> —.Appfox, Depth ❑ Eastern Su r <br /> CJ Irrigation t2 <br /> Repair Work Done U Type of Pump, H,P. <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION G (Nailableo septTic systithinem <br /> permfeetitled if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: 4r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments ` <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest. Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines _ Total length/size- <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to'nearest: Well Foundation Property Line (;?3 <br /> DISPOSAL PONDS D A u <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and M <br /> rules and regulations of the San Joaquin :County t 1 <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 of sub-contracting signature <br /> aenifies the following: "I certify that in the perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensa-tion laws of California." - I <br /> I The applicant mu call Ior all quired ins coons. Complete drawing on reverse side. f ; <br /> Signed Title: Date: <br /> FO DEP TMENT USE ONLY ri <br /> Application Accepted by <br /> Data Y Area <br /> jPit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 3Ti1 Al I AC,4w c` _` �n�� k <br /> Applicant ^ Return all copies to:- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES tT �t G ` <br /> }}4 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ?�erc_ -t-- Jt <br /> µ a1445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 8 201 �J T <br /> FEE AMOUNT UDUE �1I AMOUNT FIEMITTED CKI CASH RECEIVED BY DATE PERMIT'NO. 1> BIZ. <br /> INFOF <br /> + EH •24IREV.111151 J� � <br /> EH A-211 rrr✓✓✓n <br />