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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ©� <br /> JUMIT EMIRES 1 YEAR MON DATE ISSUED "T V_Asf0x?> <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 couplisncea with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �_ �s , �,,,, _,-__ City Lot Site/Acreage <br /> t• <br /> Owner's Name r�r , ddress ...-- �L'���, hone <br /> Car S A 77� �' f <br /> o f actor <br /> ddress ,�`."� 6�/fi� ��i�' License No, 49Phone <br /> TYPE OF WELL/PUMP. i NEW WELLX WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl <br /> IPUMP INSTALLATION SYSTEM C] 3 t:s• OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ Ac0� 2.1/_ SEWER LINES DISPOSAL FLD.� PROP. LINE Jam. <br /> FOUNDATION � AGRICULTURE WELL a OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS It <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ADomestic/Private Gravel Pack"' C3 Tracy Type of Casingcifications illlld&irk <br /> M Public �l:IO�ther ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 irrioation v2imj,Approx',,Oepth '❑ Eastern Surface Seal Installed by _ <br /> Repair Work Done C] Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter - Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADOtTION Irl DESTRUCTION M (No septic system permitted if public sewer is <br /> I Ii ,1L available within 200 feet.) yJ <br /> Installation will serve: Residence Commercial— Other <br /> i <br /> Number of living unity. i Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0. *Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ r: /x Method of Disposal <br /> Distance to-nearest: Well Foundation L Property Line r{j <br /> LEACHING LINE Cl No. 8 Length of lines ' Total length/size <br /> FILTER BED C:) Distance to,nearest:" Well Foundation ` ` Property Line r <br /> SEEPAGE PITS 11 'Depth Size w Number <br /> -.,-SUMPS LI Distance to nearest: Well Fouridation_ Prpperty Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this'apphcation and that the work will be done iii accordance with San Joaquin-county ordinances, state laws, and <br /> rules and regulations of the San Joaquin,County,, - <br /> Home owner or licensed agent's signature certifies the following: "I comity that in the perfbr�mance of fhe work o which thispermit is issued, I shall, of <br /> employ any person in such manner_as to become subject_to.wor"kman;s compensation laws of California," Contractor's hiring orsub-contracting signature <br /> certifies the following; "I certify that in Itfe peAormanGs of the work forwhich-this permit is issued, I shall employ persons subject'to workman's compenss- <br /> ~tion laws of California," 4A.a s _. ..T __, w.-.,."_ <br /> r:. <br /> The applics m f all r tions..Complete drawing on (e side. <br /> Signed <br /> S Tide: Date: <br /> FO DEPARTMENT USE ONLY <br /> 1 1' )-Application Acctipted by or <br /> 1 } Data �" �^ 1 Area <br /> Pit or Grout Inspection by � Y,` Date 6 , Final spectioniby -Date u <br /> Additional Comments: f < <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC H8 LTH <br /> 38RVICES NJ � <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE aMOukf.,REhiiTTED ",CAS'H`11 . RECEIVED BY DATE PERMIT'N�O. �A/)� <br />