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i - APPLICATION FOR PERMIT <br /> SAN- JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HTsALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> .PERMIT EXPIRES :1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San-1 <br /> Joaquin County for a permit to construct and/or install the work berein described. <br /> This <br /> application to made in compliaacelwith Ban Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County�Publi`c Health services. <br /> .XJob Address / i � ,gessf3f _ r City Lot Size/Acreage <br /> Owner's Name . ddress s Phone �` 441..11 <br /> Contractor FOS Vve"k bW�4C Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION XOut of Service Well ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ - DISPOSAL FLD. PROP. LINE <br /> W <br /> FOUNDATION AGRICULTURE ELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type,of Casing— Specifications N <br /> V) Public1 f.7 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation t4fl Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done .0 Type of PumpState Work Done I <br /> Well Destruction 0, Well Diameter Sealing ICLterial i_Depth r , <br /> <C Depth. - Filler Material.i Depth . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION..I-I. INo'septic•system permitted if public sewer is <br /> + avails Is within 200 Idet.l <br /> Installation will serve:, ReWdence Commercial��-'? Other ' <br /> Number of living units: 'Number of badroom� <br /> Character of sop to 0-depth of 3-fest - -- i i <br /> 4Vater,-table_depth J <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. G7 Method of Disposal r ' <br /> y <br /> .r Distance to nearest: Well Foundation .Property Line <br /> LEACHING LINE ❑ No. iL Length of lines To-til length/size <br /> FILTER BED ❑ Distance to nearest: <br /> J. Well FoundationProperty Lina <br /> l i <br /> SEEPAGE PITS 11 Depth ; Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS py <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and a <br /> rules and regulations of the'San Joaquin County • A <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 OF subcontracting signature .{ l <br /> certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall emptoy'•persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant mus-Call f/or�+Il to inspections. Complete drawing on reverse side.rwd y <br /> eKsig Jr '. Data: / 1 <br /> ` DEPARTMENT USE ONLY G <br /> Application Accepted by FOR /1441 Date <br /> Pk or Grout Inspection tryDate Final Inspection b - net 4 <br /> Additional Comments: ,7 <br /> • LA ( 9 <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services �W t•�1Q1 t <br /> -� En vironmental 'Health Permit/Services <br /> 445 N Ban Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DVE AMOUNT REMITTED K <br /> INFO CASH RFTIVED BY DA PERMIT NO. <br />��. Eli 17.21 IRE1r,1/ 25 01.51 W ( .0-0 `C> \ <br /> EH 11.21 <br />