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APPL1 CAT, FOR PERMIT V.1 <br /> s> 9, . <br /> SAN JOAQUIN COUNTY PUBLIC REALTB SERVICES �E• <br /> ENVIRONMENTAL HEALTH DC�ISION95201 <br /> ? � <br /> w P O BOX 2009,(209)S4 8-3447 MAY 2 Q 1999 <br /> ncvtlTT T+XIRES 1 YB1OM PATE I-'2�-ti� ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate} hFRPdIIT✓�;f,RUI0{ <br /> work <br /> Application is'hereby made to San Joaquin CountCounty <br /> ordinance nNo. 549struct and/or install eherein described. s <br /> and1662and the Rules andRegulationsof San <br /> application is made in C=Wliance with San Joaquiny <br /> Joaquin County Public Health Services. <br /> M LI,L)% L e�,r� City Lot Size/Acreage ` 1 <br /> Job Address <br /> Phoncql.' .4 <br /> Address 1-6 11 <br /> Owners Name`�� L <br /> • ContractoAddress Lo 57/J Sam I License No. 0 Phone 'QW4 /t <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION D Out of Service Well D <br /> STALLATI L.• YS'T11 R OTHER D Monitoring Well <br /> DIIS)CE�ONT)4STSTANK 1 SEWER LINES __W , DISPOS ROP. LINE , <br /> FOUNDATION SO AGRICULTURE WELL5�09L OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation , Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Vyprk 0one _ <br /> Well Destruction O Well Diameter Sealing Material i Depth N <br /> Depth Filler Material i Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION ❑ INo septic system permitted it public sewer is <br /> • vailable within 200 to .► <br /> Insta n will serve: Residence Commercial_ Other <br /> Number of r units: Numbe bedrooms 111 <br /> haracter of wil to "id <br /> of 3 feet: Water t le depth �'yl <br /> SET ANK ❑ /Mfg opacity No. Compa nts <br /> PKG. TREA ENT PLT.❑ thod of Oispos <br /> Distance to est: Well Foundation Property Lin <br /> LEACHIN L1 b Length of lines Total length/s': <br /> tn! <br /> ED n is rest: Foundation Property Line <br /> SEE TS I I Depth Sise Numb <br /> SUMPS Distance to no, 1 ono Pro Lins <br /> DISPOSAL POND O <br /> I hereby certify that 1 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 licensed agent's 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 compensa- <br /> tion laws of California." <br /> The appqan ions. Complete drawin ere de. <br /> Signe 4: <br /> g tleDate541 <br /> : <br /> rCYI9Z�� <br /> R DEPARTMEI-JNT USE ONLY <br /> Application Accepted byq9 Date� Area v p <br /> Pit or Grout Inspection by Date �o-172 Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EN 13'7�4 111EV.1/n Sr SgR0 C6 i <br />