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APPLICATION <br /> 9 P <br /> / SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> C 445 N SAN.JO' AQi1IN, PHONE (209)468-3420 <br /> P 0 BOX 2009; STOCKTON, CA 95201 <br /> -PERMIT SPIRES I YEAR FROM DATE I <br /> S ii <br /> (COmplete in Triplicate) <br /> Application is hereby made to San Joaquin County for &.permit to construct and/or install the work herein described. This <br /> application is made in Health <br /> &nceServices. <br /> with San Joaquin County, Ordinance No. 549 and 1$62 and the Rules- aad Regulations of San <br /> Joaquin County Public Health`Ser�rice'sr. <br /> Q0 ice( i�G ,r�11� r l <br /> Job Address City rlt_. Lot '31ze/Acreage '1fIZ}� '�-�-Z <br /> Owner's Name <br /> ,-� �Ll UC V-1 Address Xr SRZ Phone q 0-5 7/5 i <br /> Contractor L� ► a Address t 7 1 D: 1�?A-i N. ST- 6,5 to Ny +C �L�� <br /> — License ho.(a2�1 �(� Phone -357 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [3 DESTRUC�T)IO{N Out of Service Well (3PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTFIER 0 (Monitoring Well (3 <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD.7� ' PROP. LINE �0 r <br /> FOUNDATION AGRICULTURE WELL LL9JIL OTHER WELL-Z 30 PITS/SUMPS V­L'�', <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation__- Dia. of Well Cssinq <br /> fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications <br /> f'I Public Cl Other rl Delta Depth of Grout Seal Type of Grout_- <br /> I I Irrigation —Approx. Depth I I Eastern Surface Semi Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction Wel! Diameter Scaling Material i Depth Sj!- 1 ,u4,d-o of <br /> Depth Z6r Filler Material i Depth 5I` olJ ) '�2- <br /> TYPE OF SEPTIC: WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_-__, Other <br /> Number of living units: Number of bedrooms <br /> Character of 900 to a depth of 3 feet- Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> Pate. TREATMENT PLT.❑ Method of Disposal f <br /> Distance to nearest: Well Foundation Property Line >' <br /> LEACHING LINE ❑ No. b Length of tines Total length/size <br /> FILTER BED ❑ Distance to neared: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS CI' Distance to dearest: Well .__ Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> _ y <br /> I hereby certify that I have prepared this application and that the work wilt be. done in accordance with San Joaquin county ordinances, state laws, and j <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature cerlirres the following: 1 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 sub-pct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i <br /> certifies the following:*1 certify that in the performance of the work for which this permit Is issued,I shall employ persons subject to workman's compensa- ` <br /> tion lawn of Cal' ia..0 J <br /> Thee lican t 1411 for all r f <br /> pp equir ins a Pa;niing on reverse side. � <br /> Signed 4 Title: C.A %Z � ����3 Date: -� � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _1 '[ -- Date Area t.r Y 3 t� ► <br /> _ I <br /> Pit or Grout Inspection by eDate <br /> Final Inspection by Date �� �s <br /> Additlonal Comments. <br /> Applicant - Return all copies to: San Joaqui County Public Health Services .� <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Sox 2009, Stkn, CA 95201FE { l <br /> (NEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> . EH 1774{11EV,I/Pis I <br /> G 0 <br /> EH 14-MM /I'V� f'd'} �.`�l- <br />