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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION — <br /> 445 N SAN JOAQUIN, PHONE (ZU 342 _ <br /> P O BOX 2009, STOCKTON, C� —\_ _ •--- <br /> PERMIT EXPIRES 1 YEAR FROW DA <br /> (Complete in TripliGa�.t��E J�',�,10 <br /> �—wry <br /> Application is hereby made in <br /> to Sam Joaquin County for a permit to construct'and/or stall the work herein described. his <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and, � and the Rules and n <br /> Joaquin County Public Health Servi�cess.� '"'e'r <br /> Job Address 2'+ 5o� c_g^e'6 City Lot Size/Acreage <br /> Owner's Name �� . . Address -B 5011 Phone <br /> Contractor Address7� �10V License No.1 Phone <br /> TYPE OF WELL/PUMP: NE WELL O WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well C <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well Pt <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 9 <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications ,,,�",�,, <br /> i.l Public fa Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Wolf Destruction 0 Wall Diameter Sealing Material A Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will'eorvo: Residence_ Commercial_ Other n � <br /> Numbor of living units: Number of bodrooms u +0 <br /> Character of eod to o depth of 3 fob., Water table depth <br /> SEPTIC TANK ❑ Type/Mfg it�y No. Compartmants <br /> f t,! Method of Disposal <br /> PKG. TREATMENT PLT.0 �V�j LT4 ��DRvicFe <br /> Distance to nearest: Well 'I l�f" jv Line <br /> LEACHING LINE 0 No. Q Length of lines T,d6ftHain1h1size <br /> FILTER BED 0 Distance to Hoar Well Foundation Prope ine <br /> SEEPAGE PITS I I Dep Size Number <br /> SUMPS CI istrnco to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cortify that I hove 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's signature conifies 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 bocomo subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> eertifts the following: "I certify that in the partormanco of the work for which this permit is issued, I shall employ persons subject to workmon'a compensa- <br /> tion laws of Califomin." <br /> Tho applicant u cell for Ell req .jod inspections. Complete drawing on reverse side. /�/� <br /> Signed 3L Title: t ��.; Date: � /q <br /> 3 _ <br /> - �0R�7yDEPART ERIT USE ONLY J <br /> L/A <br /> Application Acceptod by Date Area <br /> Pit or Grout Inspection by ate 2 Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> ,(C,ASH RECEIVED BY GATE PERMIT'NO. <br /> . EH 13-24(nEV.I/xs) �C VD �J ,oD �'{��� -gr/47 3fl &W <br /> EM 14.27 CJ 1 y <br />