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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r.k DTE S r <br /> PERMIT EXPIRES Y FROM <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. h <br /> City �TX� Lot Size/Acreage O 0 <br /> Job Address <br /> r <br /> Owner's Name �6l1lL ��-y�Y Address, <br /> Phone <br /> s <br /> Contractor FLS i> G• L&e;N 'Address /�• SEL F License No. �L '�� 7w Phone 9 7 <br /> TYPE OF WELL/PUMP: NEW WELL F-1 g. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L7 <br /> -PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES. DISt� OSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bonam ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pick 0-Tracy- i--•--Type of Casing_ Specifications <br /> FI Public Ll Other °' n Delta Depth of Grout goal Type of Grout <br /> r I I Irrigation Approxi Depth I I Eastern 4s Surface Seal Instailed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> WeH DesDestructionmSealing Material i Depth <br /> ctfon ❑ Well Dia <br /> eier � <br /> Depth Filler P4►Lerial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIONX DESTRUCTION I I JNo septic <br /> lable shin system Perfretted if public sewer is <br /> Installation will serve: Residence��Commercial -Other <br /> Number of living unity. , <br /> Number of bedrooms <br /> Character of soft to a depth of 3 feet{�a r. LA Y Water table depth <br /> SEPTIC TANK © Typ*1Mf9 �X I_ii 12 AJ_CE `- Capacity o No. Compartments 4 <br /> PKG. TREATMENT PLT.C7 Method of Disposal <br /> Distance-.to nearest:' Well Foundation Property Line <br /> 11 44 <br /> F. LEACHING LINE WK No, 8 Length of lines ��"� v �' Total length/size <br /> ' FILTER BED ❑ Distance nearest:~ Well. /eQ ' Foundation_ t" Property Lina _�� - <br /> SEEPAGE PITS 17 Depth ^t Size (s o Number <br /> SUMPS L1 Distance'.to nearest: Well 1� Found0oh �d Property Line <br /> P DISPOSAL PONDS Cl .1 <br /> 11 <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County <br /> Homs owner or ticensed 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, I shall employ persons subject to workman's Compensa- <br /> Wn laws of California." s ` <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Gam. 5. 6/S-TrrX Title - ��r - - .__ Data: -�.3 <br /> - FOR DEPARTMENT USE ONLY <br /> Application Accepted by l��l -- <br /> LAJDate Area Z <br /> Date <br /> Additional <br /> Pit or Grout inspection by � Date Final inspection by <br /> Additional Comments: <br /> it <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 GASH RECEIVED BY OATE PERMIT"NO. <br /> INFO <br /> 13 '3 3 <br /> . EH 13-24IREv. 5 <br /> fia6, /' -�s <br /> "7� .��^ 1 <br /> fH 14.M ///��� // <br />