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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Q(�t Z�: <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 4 , or - <br /> P 0 BOX 2009, STOCKTON, CA 95201 3 1992 <br /> PERMIT FZPIRES 1 YEAR <br /> _FRLM 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 vIth Ban Joaquin County Ordinance fio. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> 8.-)43 dr. Li3y2J city A<_W Lot Size/Acreage <br /> Owner's Name Address +oq L ;*/DbJ)Phone <br /> Contractor U-AUkASAL Address_W6 Z. �R! CtCL�License No. (MZu—Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM OTHER OTHER .0 Monitoring Well, C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial , 0 Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack7 0 Tracy'.­. Type of Casing Specifications <br /> Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> Irrigation' ApproX, Depth <br /> I I Eastern Surface Seal Installedby <br /> Repair Work 004 0 Typs.of PumpH.P. , State Work Done <br /> Well Destruction ❑ Well I Diameter SealingMaterial & Depth <br /> Depth 16b r Tiller Material & Depth <br /> TYPE OF SEPTIC WOfIK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system Permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will so": Residence— Commercial— Other <br /> Number of Hying units: — Number of bedrooms <br /> Character of soft to a depth of 3 test: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance. to newest: Well Foundation_ Property Line <br /> LEACHING LINE CI No. 6 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to newest: Well Foundation— Property Line <br /> DISPOSAL PONDS 0 <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 Son Joaquin County <br /> Home owner or licensed. agent's signature certifies the following: 1 certify that in the performance of the work for which ihis'perrnii is issued, I shall not <br /> employ P8 n such rr' as to become subject to workman's compensation laws of California,"Contractor's hiring or sub-contracting signature <br /> y Per or <br /> an 1�,IoaarrZn <br /> certifies the f i rtl that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lam Csi im. <br /> The applWies t call for ail r ed in ns. Complete drawing on reverse.side, <br /> Signed Title: <br /> &2L&4&A' Date,. <br /> POR DEPA114TIMEN USE ONLY C) <br /> Application Accepted by <br /> Date <br /> Arse ` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Cwnmants: <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 /> INFO FEE AVOUNT DUE AMOUNT REMIT-TED K JECEIVf0 BY 6ATE PERMIT'No <br /> EH 1344(REV.I I no) <br /> vow, <br />