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APPLICATION FOR PERMIT y�� <br /> SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIR0NMENTAL,,1HEAT TH DIVISION <br /> Y 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 I <br /> PERMIT EXPIRES 1 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 Public Health Services <br /> ! A <br /> Job Address ag `/ 1' City f Size/Acreage <br /> 'S , <br /> Owner's Name Address - '+r ��t L b S b -- Pa � V <br /> Contractor [ZRAddre�ShL__4&0Licensexhlo.�b23�,"'S'Phone .7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl y DESTRUCTION V15ut of Service well ❑ <br /> PUMP INSTALLATION 05YSTEM REPAIR 190 OTHER ❑ . Monitoring well n t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,DISPOSAL FLD. PROP. LINE <br /> FOUNDATION =A.GRICtJL-TUAE WELL- OTHER WEZL PITS/SUMPS <br /> iNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> Cl industrial ❑ Open.Bottom ❑ Manleca—�Dia:.of Well Excavation Dia. of Well Casing <br /> E] Domestic/Private ❑ Graves Pack ❑ Tracy Type f Casing Specifications <br /> . - <br /> Il Public 171 Other Cl Delta Depth of Grout Seal _ Type-Of Grout '�- <br /> I I Irrigation -.Approx. Dep Eastern Surface Seal Instilled_tW <br /> Repair Work Doneol/Type of`Pump' 5 H.P. Stat ork Dona <br /> Well Destnrctian <br /> Well Diameter.- }- k:,Sealing 'Material'& Depth {� <br /> Depth - r ller_Mute ial,i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower is <br /> --� - - . - . , 't available within 200 feet.) <br /> Installation will serve:-. Rtlsidenirs Commarcial_ Older <br /> �. ,. <br /> Number of living units: Number_o. - O,00ms s�' t } <br /> Character of soil to a depth of <br /> teat: Water table depth ' r� <br /> SEPTIC TANK ❑ Typi/Mfg: �' ' 'Capacity No. Compartments f <br /> PICC.. TREATMENT-FLT. CI t s } Method of Disposal <br /> Distance to nearest: II Foundation s` Property''Line " <br /> LEACHING'LINE C1 No. i Length of line - Total length/size <br /> S • <br /> FILTER BED CI Distance to'neare Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 1ZSize -2 Number f f <br /> SUMPS Ll Distance to nearest: Well oundation Property Line f <br /> DISPOSAL PONDS ❑ <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 San Joaquin County <br /> Home owner or licen signature certifies the following: "i certify that in the performance of the work for which this permit,is.issued,•1 shall not <br /> employ any per in such man as to become subject to workman's compensation Isws,of California,"Contractor's hiring dr sub contractingsignature <br /> certifies the fo ing: "I certify t t in the performanc a work for which this permit is issued, I shall employ persons subject to workman's conipansa• { <br /> tion laws of ifornls." i <br /> The applican must Lir c let drawing onda, <br /> Signed x T Title: Date: jErw~ <br /> . .tin <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by-, Date <br /> Pit ar r I tion by Data Final Enspe/coon by Data st <br /> ! ` r <br /> Additional Comments: t <br /> Applicant - Return ail 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 dry <br /> FEE jAM0UNjTDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO.INFO EN 1111 IR ( r� <br /> EN S�•16 r I ` <br />