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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 /> I P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> } (Complete in Triplicate) <br /> the vert herein descriDed.l This <br /> Application is hereby made to San Joaquin county for a permit to construct and/or install <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1662.and the Rules and Regulations of San <br /> Joaquin County public Health Services. <br /> 77e W' Fgka,5 ler 2D City LA7ry_P Lot Sire/Acreage / 4 <br /> job Address I <br /> Address <br /> Phone ` <br /> Owner's Name Y�.5��20 s�+"'� - <br /> STK+1 Phone S- " <br /> Conhacta FLAYD Woop Address AJ, ADEL6ER7 9t}IS' License No. <br /> TYPE OFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DES?RUCTION C1�Out Monitoring Yel1 U <br /> PUMP INSTALLATION ❑ , <br /> SYSTEM REPAIR ❑ OTHER O <br /> DISPOSAL FLD <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS �-- Dia. of Well Casing <br /> Dia. of Well Excavation <br /> Cl Industrial ❑ Open Bottom ❑ Mantscs Type:of Casing_ Specifications <br /> f.l Domestic/Privata ❑ Gravel Pack ❑ Tracy Type of Grout <br /> I'1 Public fl Other f1 Delta Depth of Grout Seal .� <br /> Irrigation —Approx. Depth I 1 Eastern Surface Seel Installed by <br /> H.P. State Work Done_ <br /> Repair Work Done Type of Pump SaliOs Material i Deptih <br /> Well <br /> I Destruction Well Diameter ' <br /> -� ►Silas Material i Depth i <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION� REPAIR/ADDITION i 1 DESTRUCTION 1 I IN'ns septic 'h ie in 2100 lreme10ed it public sever n <br /> Installation win serve. RaideAu✓ Commercial _ Other <br /> Number, of Irving units: _�_ Number of bedrooms L Water table depth <br /> Chwactw Of and to a depth of 3 feel: I Siy�l9 Z <br /> SEPTIC TANK ❑ Type/Hip OW-L Capacity 12-00 No. Comportrrrnta <br /> k -+ Method of Disposal = <br /> PKG. TREATMENT PLT. ❑ 1a, t ' <br /> Distanceto nearest: Wag /Od7t Foundation � Property lila <br /> i <br /> -20 Total length/size . <br /> LEACHING LINE L�No. 8 Length o1 tines 2 r r <br /> FILTER BED O Distance to nearest: Wall /nd r Foundatwn - Property line <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS LI Distance to newest: Weal Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 hereby conify that I hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, nus lam, on, <br /> r. <br /> rules and regulations of the San Joaquin County <br /> Homeowner Or licensed agent's signature certifies the following:_1-C@rtity that in the part Of the work for which this permit is issued:I Mall not <br /> employ any Person in such manner as to bacorne wbjeet to workman's componestion lam of California." Contractor's hiring or sub-contracting signature <br /> rmsnce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> certifiss IM following: "1 pertify that in rho pano <br /> tion laws of CelIfOrri It <br /> The applicant must all for ad required inspections. Complete drawing on reverse side. - <br /> Signed <br /> Title: 57 <br /> Date: _,' <br /> F EPAR T U / <br /> Due o/ na <br /> Application Accepted by <br /> Date Final Inspection D Data <br /> Ph or Grout Inspection by , <br /> Additional Conwnants: <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health permit/services <br /> 445 N San.Joequin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT REMITTED K RECEIVED!9Y DATE PERMIT NO. <br /> INFO AMOUNT DDE ' p <br /> En 1124 IRE ,I,.,i . tear j d;7 40 <br /> EN 14-M <br />