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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM 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 is made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealthServices <br /> Job Address �6 / City Sm /cy'01t Size/Acreage <br /> .SA C 9/"6 - <br /> Owner s Name �,/C C'I'gi-� ��/ ddress f �5 ��/�ll'Q.'JG E 1V4X- Phone <br /> Contractor �✓� !/rAddress t 7";" Rlo ✓/` `�L°[cense No -S�/�-77 Phone — .2 <br /> v v3 Gd <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT C7 DESTRUCTION 0 Out of service well 0 <br /> PUMP INSTALLATION E7 SYSTEM REPAIR ❑ OTHER ❑ /-14onitoring well <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 y rr <br /> Cl Industrial ❑ Open Bottom 0 Manteca Dia of Well Excavation Dia of Well Casing <br /> 1'l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing C Specifications '0/0 <br /> I 1 Public 1-1 Other 1`I Delta Depth of Grout Seat Uh^` T �r x <br /> ypa of Grout 7J CiIU <br /> I I irrigation Z:2 Approx Depth i I Eastern Surface Soul Installed by riT vin <br /> Repair Work Done U Type of Pump H P State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Materials Depth Yj- LWL Z <br /> Depth Filler Materials Depth �5/s5 SX /� 7y- y� <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted it public Lew6r IS <br /> Installation will serve Residence_ Commercial__„_- Other available within 200 feet ) <br /> Number of Irving units Number of bedrooms <br /> Character of soft to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- No Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE Cl No 6 Length of tines Total length/stze <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> Home owner or licensed agent s signature candies the following I cenify 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 become subject to workman s compensation laws of California Contractor s hiring or sub-contracting signature <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 a compensa <br /> tion laws of California ' <br /> The applicant must call for all required inspe lions Co awing on reverse side <br /> Signed �G�✓ Title F/l Date <br /> FOR DEPARTMENT USE ONLY 2qt co S7 <br /> 1 <br /> Application Accepted by i ✓� --- -- Date Z Area 11i <br /> PrI or Grout inspection by Date Final Inspection by Date <br /> �ddrtional Comments <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C K i RECEIVED <br /> BY DATE PlE1RM17 NO <br /> 13-74[REV irnsi �� Cv �� %rL N <br /> 14 29 <br />