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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 /> R <br /> (Complete in Triplicate) in <br /> work <br /> Application is hereby 04e.toaSan ri°thu9snCJoaquin°Counr a ty Ordinancermit to nNo 54gstruct 8ando1862 and ther install eRules aadeReBu tionadof Sans <br /> application in tsa,de,in coetpl � <br /> JOKuin County Public Health Sery/ices. <br /> et/' City Lot Size/Acreage <br /> Job Address # / /,I I 9,Sz <br /> ? �J�4 P Phone <br /> Address ./' ,{� /� <br /> Owner's Name QX/ ?7 / `" 7✓l}�l <br /> J License No. ���37 Phone <br /> �/� (/ f r Address <br /> Contractor WELL REPLACEMENT 17 DESTRUCTION ❑ put M Service Well C7 <br /> NEW WELL ❑ OTHER D Monitoring Well <br /> II TYPE OP WELUPUMP: A SYSTEM REPAIR D <br /> PUMP INSTALLATION ❑ DISPOSAL PLD. PROP. LINE <br />'I SEWER LINES �--�— PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- AGRICULTURE WELL <br /> FOUNDATIOOTHER WELL_�.�— 4 <br /> N �— J} <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CATIONS Oia of Well Casing f� <br /> EI Open Bottom ❑ Manteca Dia. of Well Excavation <br /> C;11 In trial Specifications <br /> ❑ Tracy Type of Casing <br /> DomsaticlPrivate C7 Gravel Pack Depth of Grout Seal Type of Groutr <br /> I1 Other ❑ Delta <br /> M P,Iblic �Surfaca Seal Installed by <br /> C1 Irrig © H.P.ation .Approa; Dept Eastern State Work Done 48 <br /> .- r (/ <br /> Repair Work Done "�''ype of Pump Sealing Material k Depth <br /> Well Destruction ❑ Wall Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIRIAODITION Ci DESTRUCTION CI aNailab4elw thin 200 festl'ied d public sower is . <br /> once Commercial — Other <br /> Installation will serve: Resid -- -- <br /> k Number of living units: Number of bedrooms Water table depth <br /> i <br /> I Character of $oil to a depth of 3 feet:i CapacityNo. Compartments — <br /> �...�--- <br /> SEPTIC TANK. ❑ Type/Mfg - Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation Property Line - <br /> Distances to nearest: Well �..--�- <br /> Total length/34e <br /> LEACHING LINE CI No. & Length of lines Foundation Property Line <br /> ! FILTER BED n Distance <br /> to nearest: Well <br /> Sixe Number <br /> i SEEPAGE PITS I I Depth ' Property Line —.�-- <br /> SUMPS 1 1 Distance to nearest: Well ---.� Foundation.� <br /> f DISPOSAL PONDS D i <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 /> " following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the <br /> employ the person in such <br /> Ich manify that n to the performance c°f�he work foswh ch this permit is issucompensation laws ofed, I shall employ apersons 1subject to wo(kman+seompensa- <br /> cert f es g <br /> tion taws of California." <br /> The applicant ust c for all c ctions, omplete drawing on re rs side. s� �� J/-2 <br /> Signed <br /> Com/} Title: / Date: <br /> 0 PARTMENT USE ONLYCt Dater--=tr Area <br /> Application Accepted by f q 1 <br /> Pit or Grout Inspection by Data <br /> Pinel Inspection by Date <br /> r — <br /> Additional Comments: <br /> Applicant - Return all Copies to: SANVIRONMENTALOHEALTH DIVISION PERMITIC HEALTH SERVICES <br /> /SERVICES <br /> 445 N SAN JOAQUIN, p O BOX 2008, STOCKTON, CA 85201 <br /> CK RECEIVED By DATE PERMIT'NO. <br /> Wgg5j! <br /> REMITTED CASH ;i <br /> {�/+, (� .2_ <br /> Z�a 1 1� <br /> . E„13.24 IREV.,,a6I '`�\ '[J6 w <br />