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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YE" FROM DATE ISSUED <br /> ,f (Complete in Triplicate) <br /> _ <br /> Application is hereby made to San IJoaquin 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. <br /> /�} Pell- a <br /> f�/J�7 Nom. q <br /> Job Address._ `-` p ie10 m ICity Lot Size/Acreage <br /> f <br /> Owner's Name ` 'M`Vf'*Xddress 5199 0 ,9TAW Phone <br /> Contractor xt C,40.53' Address Sr.eofs �0cense No, ? --� Phone� 77 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMEN DESTRUCTIO of service tfe11 ❑ <br /> PUMP INSTALLATIO SYSTEM REPAIR .OTHER O Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER-LINES...,-_--- m DISPOSAL FLO.J!D2 PROP. LINE �. . <br /> FOUNDATION CO~ AGRICULTURE WELL OTHER WELL PITS/SUMPS /. <br /> INTENDED USE TYPE OF WELL ..,,'PROBLEM AREA ' '-CONSTRUCTION SPECIFICATIONS <br /> C_fJ- 1!nduitrial W "—O Opin_Batiom' w "Cl Manteca Dia.o�Well Excavation ` " 'Dia.af'WeiE-Casinp <br /> [+womestic/Private CiL Crravel Pack ❑'Tracy k Type,of Casing_ r Specifications- r <br /> I'I Public f-1 Other I"1 Delta Depth-of Grout Seal aOType of Groat_7_f,+ - <br /> I I Irrigation 5 .Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done U T { <br /> p Type o1 Pump y�aa� = H.P. 2, � - State Work Dons._ <br /> Well Destruction ❑' ~Well Diameter Sealing Material'i Depth <br /> Depth 4 "f .Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION P-I_REPAIR/ADDITION I'1' DESTRUCTION I I INo septic system permitted if public sewer is, <br /> > ' available within 200 fest.l i <br /> Installation will serve: Residence_� Commercial_ ,Other <br /> Number of living units. Number of bedrooms <br /> Character of-sogZO�-d of 3 feat: '' 1 f- Water table depth <br /> SEPTIC TANK. ❑ Type – ' Capacity No. Com s <br /> PKG. TREATMENT PLT. ❑ "* of Disposal <br /> c Distance to erest,__;_.Wall_ - ion Property Line <br /> Y LEACHING LINE' Cl No, b Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: e.Foundation Property Line <br /> SEEPAGE PITS 11 Dept Size Number <br /> SUMPS istance to nearest: Well 4 Foundation Property Line <br /> DISPOSAL POND .O <br />„ � y I hereby certify that I have preparedlthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws,-and <br /> rubs and regulations of the San Joaquin County 'e .. <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 'hall 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�"Ich this permit is issued, I shall employ persons subject to workman's compensa- <br /> b� 'ion laws of California." <br /> The applicant us II for requ' inspections. Complete drawing on reverse si e. _p <br /> Signed Title: k.11, Date: l` — T*Z, <br /> R DEPA 7--USE ONLY <br /> Applicat n Accepted by Date I L —I Area <br /> k <br /> Pit I r Inspection by ' Dat Final Inspection by Date <br /> Additional Comments- <br /> Applicant <br /> ! <br /> k Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental- Health Permit/Services <br /> _ 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FFD. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . Er,13.24(REV.I/w '� Y4 <br /> 1" U <br /> EM I42D -� - - <br />