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f R APPLICATION FOR PERMIT <br /> F •�. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> 't ENVIRONX&TAL�HEALTH DIVISION <br /> _ 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSEED _ <br /> (Complete in Triplicate) <br /> Appiication 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 c(trliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address : D&92 a e City Lot Size/Acreage 73 <br /> c�Qlcr 9Sas�Q <br /> I]]� P r �j <br /> r✓re 7[t�9 �.J�! �e! — Phone r -C/ <br /> Owner's ams• �� � ��. �..,�„ - � '� -�-,,`�• <br /> Contractor- -4 - 3 -Address�f�=�-a:a-o�L�-ICI) --- License-No; - -Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C7 DESTRUCTION Cl Out of Service Well L7, <br /> 4 _ PUMP INS/TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES a� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATI N <br /> ` 0 Industrial ❑ O&n Bottom ❑ Manteca Dia. of Weil Excavation Z fit -Dia. of Well Casin <br /> a _��� �-,.� <br /> h arl'Domastic/Private P ravef Pack ❑ Tracy Type of Casing_ .G Specifications <br /> } f•I Public 1"1 other. 1-1 Delta Depth of Grout Seal Type of Grou <br /> 1 i Irrigation 1 .Approx. Depp0m I I astern rf a Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 13 Wali Diameter Sealing Material i Depth OQ <br /> - Depth s tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> } i (( ;' i I ' available within 200 feet.) <br /> Installation will serve: Residence T Commercial-'i Other All <br /> Number of living units: Numbs of bedrooms t f <br /> r (+�►'► <br /> q Character of sob to a depth of 3 feet: 1 t' 1 Water table depth <br /> SEPTIC TANK. ❑-{ Type/Mfg Capacity--L—d No. Compartments _ <br /> PKG. TREATMENT PLT. CI I� $ i. `_ Method of Disposal, �. <br /> F Distance to nearest: II 1 Foundation Pr { <br /> M � � operty Line <br /> LEACHING LINE Ll No. 3 L ngth of fin _ Total length/size D� <br /> FILTER BED ❑ Distance to near t: Well Foundation Property Line <br /> SEEPAGE PITS II Depth Sire \Numb t• <br /> SUMPS LI Distance to nearest: Well ° �ndatioh rr� Property Lime <br /> DISPOSAL PONDS ❑ r <br /> I hereby c9nify:that I have prepared this-application-and-that-the-work-will be done in accordancefwith San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county <br /> Home owner sn agsnl's aignature certifies the:following: "I certify that in,th-e�performance of"the work for which this permit is issued, 1 shall not <br /> employ any raon in su manner as to become, ct to workman's compefs�aki laws-of California:.," Contractors hiring or subcontracting signature <br /> eartifiea t iallowing:"I rtify that in 'perfor, rof the work for which this-permit is issued, I shall employ persons subject to workman's componsa- <br /> t tion 1 of Calif rnla." <br /> 4 <br /> The ap icon at or all mp ate drawing sid C] <br /> ' Synod /rd rue: — Date: �Z <br /> FOR DEPARTMENT.USE.ONLY <br /> Application Accapisd b�ij -.r `"Date '�~ �-�~ Area 46r`7..[ f <br /> Pit or J061 Inspection by ate Final Inspection by_ -Date <br /> e_ <br /> Additions! Comments: ' <br /> > Applicant - Return all copies to: San Joaquin County Public Health Services e <br /> Environmental Health Permit/Services" { <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE e <br /> I FO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY p TE PERMIT•NO. <br /> . EH 17.21(REV.I/K 5) Q' <br /> r fM it-Za . E.c - r r- <br />