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j' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH "DIVISION �ygt/ b� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 GGff)0 64FN/V jLtBQi <br /> YEAR <br /> ' Y S7 E ov (Complete in Triplicate) <br /> Application in hereby made,to San Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application Is made in colspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. IKAJ /6 3 -1"70 -41e <br /> Job Address /V�G NIn f GE City Lot Size/Acreage <br /> �e Address _ IZ99 &Se MdD�;51� f4 Phone <br /> t <br /> • CaniracioAddress tb ZLicense No, N4�2-6� . Phone L/A•- <br /> 4 <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 1'Sr <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 10r/.Sj` A f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d Jr >d1MP, <br /> n Industrial 0 Open Bottom C Manteca Die. of Well Excavation cresimo <br /> U Domestic/Private C Gravel Pack 0 Tracy Type of Casing s LIQ+ C <br /> M Public Il Other lC Delta Depth of Grout Seal ,' Out <br /> CI Irtioation —Approx. Depth 0 Eastern Surface Seal Installed by i717L�1� 7-7 rr-tp P�bk <br /> Repair Work Done L3 Type of Pump H.P. State Work Done lAW LC"-e 7' i <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence— Commercial_ Other ! <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments GA <br /> PKG, TREATMENT PLT. Cl Method of Disposal ` <br /> Distance to nearest: Well Foundation Property Line <br /> V <br /> LEACHING LINE 0 No. & Length of lines Total length/sire <br /> FILTER BED fl Distance to nearest: Well Foundation Property Line 0 <br /> i <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS C <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i <br /> rules and ragulationaol-the San Joaquin County <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 or sub-contracting signature <br /> comilies the following; "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant rnpq call for all r rived inspections. Complete drawing on reverse side. <br /> Signed X +i-p Title: AEN6, pSIST Date: S��� <br /> F R WARTMENT USE ONLY CC� <br /> Application Accepted byAw-wDate S Area <br /> 41 <br /> Pit or Grout Inspection by Date Final Ins, etion by r Date 5 <br /> Additional Comments; �-��``r a e <br /> Applicant ^ Return all copies to. .BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 945 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK NASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> • EH 13.241REV,U"5) <br />