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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL <br /> P 0 BO% 20 9, STOCKTON, CAI 95201 1Ica <br /> (209) 468-3447 <br /> PERMIT_EXPIRES 1 TFAR OROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a Permit to construct and/or install the work herein described. This <br /> application In made in coaWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County �r <br /> Public Health Services. <br /> Job AddressLI) L goo �L14 / <br /> %r {;a _ City kAI1 —f Lot Size/Acreage <br /> 234711M<— <br /> Owner's Name ���.�� �� . , E� _ Address �• O 0�/ r elr_4 4711 �<— Phone , * �` <br /> • Contractor - �i�. t.1-( _ 'rye � -Address`;�•f =��'�f!'�=��„�'t�.':f"t``i. -._-�ieense-No�`��..�?ci�1 -Pfiton �/ -�- '� <br /> TYPE OF WELL/PUMP: NEW WELLV WELL REPLACEMENT C'1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring-Well <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD,S�1PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS_r'' , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIPNS <br /> fl industrial >.ppen Bottom ❑ Manteca Dia, of Well Excavation 4 • Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casino— Specifications <br /> ❑ Public l-1 Other ❑ Delta Depth of Grout Seal Typ of Grou : <br /> M Irrigation aS Approx. Depth ❑ Eastern urface Seal Installed by ��_f t 1" +��e <br /> Repair Work Done 0 Type of Pump n;.21, N.P. State Work Done <br /> Weil Destruction ❑ Well Diameter Sealing Material i Depth .r <br /> b it Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L3 REPAIR/ADDITION CI DESTRUCTION CI (No 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 ' <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size a <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I LZ-Depth Size- '"'r Number <br /> SUMPS �Ll� Distance�to nearest:-•-""WeIIII Foundation Property Line . <br /> DISPOSAL PONDS ❑ 4 �'~' <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 <br /> rules and regulations of the, Joaquin County <br /> Home owner or licensed agent's signature certifies the following:-'f ie'rtify that in the performance of the work for which this permit is issued, I shall not <br /> employ any portion 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 comity 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 Californis:"— <br /> The applicantmustcall for all required inspeetions. Complete drawing on reverse side. <br /> SignedZ—,� Title: fi=r Date: 1 <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by + Date l Area / <br /> Pit or Grout Inspection by Date Final Inspection by <br /> I <br /> "^"'Additloniil`Comrtiirits: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 446 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK :A.ECEiVED BY DATE PERMIT'NOr.— <br /> + EH 17.24 tREV,t/MS) 1 3 r O� A- Q l,��llc-� W - <br /> r9i —hLt~ c—,4 P <br />