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APPLICATION FOR PERMIT <br /> X11) tJ�l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> `� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> JAG P O BOX 2009, STOCKTON, CA 95201 <br /> PARKLT EXPIRES 1 YEAR FROMI DATE ED <br /> 'r .�O,l� .� (Complete in Triplicate) <br /> Application ie hereby made.to San Joaquin County for a permit to construct and/or install the work herein descrfbrsrl. Th4R <br /> JoequintCounty PPuublicnHealthiaervioe®h t3~„ Joaquin County prdlnanae Nn. 51r9 and 1860 r+nrl #irr sEuta■ rsn4 Regulations of San <br /> Job Address j- ` <br /> City SJ Lot Siz Acres X <br /> Owner's Name ♦ KCI ft /Z1,1 `t t <br /> Address - .,. il ... �''Of'L1C <br /> ��_ Phone <br /> Contractor 1. (r/'t�`SS� Vin•?5 Address - <br /> License No. r i Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. =: PROP. LINE -„5` <br /> FOUNDATION _ _ AGRICULTURE WELL 92 OTHER WELL PITS/SUMPS- <br /> INTENDED USE _TYE OF•W—ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial pe[�p n Bottom L7 Manteca Dia. of Well Excavation <br /> f I Domestic/Private ❑ Gravel Pack Dia. of Well Casing IZ <br /> [J Tracy Type of Casinq � j[C Specifications - <br /> f'I Public --- <br /> / 1.1 OthAr wo i� pelta Depth bf Grout Seal {D <br /> Ilf''rrNTatlon JJ � l�� '-`�' Type of Grout_LSctl--f" <br /> AP(W5`x-D`FP-M I I Eastern <br /> 5urfaee Seal Installed by <br /> Repair Work Done U Type of Pump H p <br /> State Work Done <br /> Watt Destruction 0 Well Diameter Sealing Material ✓G Depth -' <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/Af)DITfON 1 1 DESTRUCTION f I INo septic system permitted if public sewer is <br /> Installation erve: Residence_ Commercial_ available within 200 TaeLi <br /> Other <br /> Numbs►of living unit -z:-- .Number of bedrooms <br /> Character of soil to a depth--.-r`3ieet: <br /> SEPTIC TANKWater table depth <br /> O Type/Mfg �y Capacity No. Compartments <br /> - PKG. TREATMENT PLT. 0 -tet . . <br /> M&ihod of Disposal <br /> Distance to nearest: Well <br /> -_ -Faundatibn Property Line L/ <br /> LEACHING LINEr <br /> L7 No. & Length of lines To length/size <br /> FILTER BED CI Distance to nearest; MR <br /> � Foundation Property Line <br /> SEEPAGE PITS I I— Dei _ Size <br /> SUMPSf I Di —.-Y— Number <br /> atstance to nearest: WWellFoundion <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify 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 San Joaquin County i <br /> Home owner or licensed agent's signature certifies the following: ' ' <br /> employ anv person in such manner as to become subject to workman's compensation laws oot California,rmance of e Contractowork for r's g or sub-contracting ch this permit is lsignanot <br /> turre <br /> certifies the following: "I certify that in the performance of the work for which this permit Is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant must Call for all require Inspections, Complete drawing on reverip side. <br /> Signed X 4L/arti/ <br /> Title: TM� <br /> Date: <br /> ` r7 (9R DEPART US.E ONLY _ <br /> Application Accepted by Z- O <br /> Date Area _ <br /> Pit or Grout Inspection by - Date <br /> Final Inspection b Date ` �-•— <br /> Additional Comments:�Applicant <br /> - Return all copies to: San J aquin County Public Health <br /> Services, Envirottmental Health Permit/Services 4- f �1�1C <br /> 1601 E. Aazelton Ave., P 0 Box 2009, ,Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVEDAY DATE ' <br /> EH 1321 fREV. WV r0 PERM17 N0. <br /> EH-4.26 tv L-� 0,I) 7 !7,-!5`) 202-- <br /> 1Z 6t7 <br /> -0E c <br /> s s• y <br />