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APPL I CATI OPS' FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 0 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> PERMIT ESPIRES 1 YEAR FRQI._2, TE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby, made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is ttmde is compliance with Elan Joaquin County Ordinance No. 549 and 11362 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address2dStn�ari a o _- _.____.— City Lot Size/Acreage <br /> LiQa,WAO -W,otrw, <br /> Owner's Name .0� r Address d tG C��Ok_ Phor�lb <br /> I .,f f!1+ , 041 ton r•h i? Gn �°�cord j Geo. o G� -G 3 <br /> Contractor rens License No. Pho <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM PfPAIR ❑ OTHER ❑ Monitoring Well rrf <br /> DISTANCE TO NEAREST: SEPTIC TANK __ ____T_ SEWER LINES � DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL Lf� OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tf 11 <br /> Ci Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casirl <br /> IF <br /> E) Domestic/Private Gravel Pock ❑ Tracy Type of Casing_ �L If Specifications <br /> 1'I Public 1:1 Other posits Depth of Grout Seal 46 S Type of Grout <br /> I I Iffioation —Approx. Depth I I Eastern Surface Seal Installed by 1 <br /> Repair Work Done L) Type of Pump H,P. Slate Work Done — <br /> Well Destruction 0 Well Diameter Sealing tlaterial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence T Cornivtorcilil— Other .,.` <br /> Number of living units: Number of bedrooms f <br /> Character of soli to a depth of 3 fret: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENt PLY.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 8 Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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, an( <br /> fulls and regulations of the San Joaquin County l� <br /> Homs 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 lit such manner as to become subject to workman's compensation taws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: 1 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant at 11 for all required spect' no. C mplete drawing on reverse ride. ' <br /> Signed Title: Date:" <br /> -- D FOR DEPARTMENT USE ONLY <br /> Application Accepted by '""�'�t DateAO <br /> �_—T Area ��o <br /> Pit of Grout Inspection by Date S �l g� Final Inspection by -~ j r Dau 2 9 <br /> Addhionsl Comments: MWte7 T 7 <br /> IfIl <br /> Applicant -_Return all copies to: San Joaquin County Public Health Services S <br /> Environmental Health Permit/Services .2-200 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IN 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM177N0. <br /> . tN1l74lltEv.„m5, �•/ ,93rs—o'j <br /> EH 1�7a <br />