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APPLICATION FOR PERMIT <br /> SANS-JOAQUIN COUNTY PUBLIC HEALTH`SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPlicatlon 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 coullliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> /Yiob Address 3�T1 T'S �6�LL lA ICiitly SSD/ e # 4 Lot Size/Acreage <br /> '/'Owner's Name in, r A nsTAddress �`�L2'b fV Q � IN (�n A If_ Phone <br /> G Contractor I Al UI) f Q Address License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Serviee Yell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPA ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WE OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL.' PROBLEM A CO TRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca la of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T asing_ Specilications <br /> Il Public (1 Other fl Delta Depth of Gross sal Type of Grout <br /> I longation _AQprox..1Depth 1 1 Ess n Surface Seai Installed by 1 <br /> Repair Work Done ❑ Type of Pum H.P. State Work Done _ <br /> WON Destruction ❑ Well Diameter Staling Material i Depth vN <br /> Depth Tiller Material L Depth } <br /> J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 DESTRUCTION I I INo septic System permitted if public rower is <br /> � available within 2W Iasi <br /> Installation will carne: Alderece_ Commercial_ Other ,x bj le �/'­"` <br /> Number of living units: --A_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: //�� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _s ites IAilj Capacity_ No. Compartments <br /> Pli TREATMENT PLT. ❑ C f r Method of E=iaposal <br /> Distance to nearest: Well +o Foundation .1 3n Property Line <br /> LEACHING LINE Yh No. 8 Length of linea _2 X S N - Tonal length/size FILTER BED ,❑1 Distance to naarest: Well 1(,a 'P Foundation _/Uj Property Line <br /> SEEPAGE PITS AO Depth Size_ dumber �. <br /> SUMPS LI Distance to meanest: Well ,/40 Foundation�_ Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 erehy certify that I hews prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and rapulahona of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies 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 become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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's compenss- <br /> tion laws of California " <br /> The appl t Wall COR to II r Wired inspections. Complete drawing on reverse side. <br /> / /5 ned %- 1 L r 13 <br /> p Title: _n rota Date: <br /> FO EPAR7MENT USE ONLY <br /> (�\\ <br /> A ieation Accepted DY ��� 1 `l ft DeA Date Area <br /> Por Grout Impaction by l n Dater ,Final Inepeetion by �`-'beti'� o�� /3 <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 O Box 2009, Stkn, CA 95201 <br /> INfO AMOUNT DUE AMOUNT REMITTED JC�/A RECEIVED BY GATE PERMIT NO. <br /> . EN 13-N IaEV.irsai <br /> EN lm.m .. .i <br />