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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I8§9M <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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> ,y <br /> Job Address 2-21 ,��/ �ECity //� /�Lot Size/Acreage <br /> i <br /> �OWner's Name- ;. ,I=���d/ - 1 �:�1 � /'� �♦ � I <br /> � � r � Address-- one_ <br /> f �--s <br /> Contractor ew; 2q. -'5' Address 1 , ' License No. Phone �1 t <br /> r` <br /> STYPE OF WELLIPUMP: NEW WELL X WELL REPLACEMENT n DESTRUCTION L-1 Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER ❑ Monitoring Well <br /> ` DISTANCE TO NEAREST: SEPTIC TANK &Q1 SEWER LINES `7 DISPOSAL FLD?. PROP. LINE <br /> ". FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> LI Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ;KDamsstic/Private Gravel Pack ❑ Tracy Type of Casing_ J2elef Specifications 47��. h s <br /> if'] Public �� Cl Other n Delta Depth of Grout Seal 0 Type of Grout <br /> I I Irrigation 3[5 Approx. Depth I i Eastern Su ca Seal Installed by -� C� <br /> r - i <br /> Repair Work Done AJ Type of Pump -:5 _ H.P. q State Work Done — 6 <br /> Pell Destruction "O Well Diameter Sealing litaterial. i Depth o <br /> • Depth Tiller Material i Depth <br /> jTYPE+OF SEPTIC WORK: t NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i Mo septic system permitted it public sewer'is <br /> available within 200 feet.) <br /> Installation_will serve: Residence_ Commercial_ Other I € <br /> Number of living units: Number of bedrooms <br /> ' § Character of loll to a depth of 3 feet: Water table depth <br /> r =SEPTIC,TANK. ❑ Type/Mfg Capacity Jr., No. Compartments <br /> x PKG. TREATMENT PLT. ❑ Method of Disposal <br /> fY �: Distance to nearest: Well Foundation'' Property Line <br /> N1.6 HING.L'INE,)r, ❑ 'No.& Length of lines Total length/size <br /> 'FILTER BED'L.►' '�.❑i Distance to nearest: Well Foundation Pro i <br /> party Line <br /> Si <br /> WAGE-PITS__- 1 .1.1 Depth-. Size Number <br /> SUMPS . Ll .Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS r I `l r <br /> I hereby comity that,l-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 /> Home owner or licensed agent'a signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ampby tiny person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature E <br /> certifies the following: "I unify that in the performance cL tjo work for which this_permit is issued,,).shall omploy.persone.subject_to workman:o}cbmpsnsa- ° <br /> tion laws•of California." _ w + <br /> The applicant or req ctions. Complete drawing on reverse side. <br /> Si <br /> Signed X Title: Data: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit rou Inspection by Date J/ Final Inspection by Date 0 <br /> Addktiortal Comments, <br /> t ' 7rtR �u�w� af'�s <br /> ;Applicant - Return all copies to: San Joaquin County Public Health Services <br /> t Environmental Health Permit/Services Ao�5 G�y��rj <br /> _A45 N.San,Joequin,- P-O,Hox,2009;-Stkn---CA-95203-- <br /> IFfE AMOUNT DUE �MdU EMITTED CASH '{ EIVED BY ATE PERMIT N0. <br /> 'EM'1V24-tltElr-1Jra1 A ""/ ► ��. /..,.....a I <br /> EH 14.26 t <br /> h <br />