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_ APPLICATION FOR PERMIT <br /> .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> )c'_ ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <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 trork herein described. This <br /> met <br /> application in made in caliance with Ban Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r 1 ��ii ` � <br /> &M KRIJ IE L �bt City Lot Size/Acreage f <br /> Job Address / , ! <br /> Owner's Name RLL N IC C01 f QL1 Address ���(O ��E W e;0b bR Phon,6W ` <br /> Contractor y Address JUDC�. E V— License No. 3 Phon FW-2� <br /> TYPE OF WELL/PUMP: NEW WELL ir WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ IrOTHER O Monitoring Well ❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK WQJ1'_ _ SEWER LINES &1061 E DISPOSAL FLD ONE PROP. LINE�f <br /> Ir FOUNDATION &104E AGRICULTURE WELLFJQbjOTHER WELLbLUd PITS/SUMPS DIY%h <br /> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial p�pen Bottom w ❑ Manteca �V rr <br /> '0 u Die. of Weli_Excav;ti'orn t , Dia. of Weil Casing <br /> D Domestic/Private ravel Pack Q Tracy Type of Casing_ J L - _ Specificationrqso ='1k?i <br /> I'I Public 11 Other {- n DeltaDepth of Grout Seal " Type of Grout <br /> rrigatiort Approx. Depth I I Eastern Surface Saul Installed by <br /> i u <br /> I <br /> Repair Work Done 0 Type of Pump SoR, H.P. (1�7 State Work Done LAiSi[�2+C AiE�l <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> I Depth Filler Material i Depth <br /> t n <br /> t PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION`(l`'DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within.200 feet.) <br /> Installation Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms < <br /> y <br /> Character of-soil.to a depth-of.3 <br /> .-„-�,- Water tablede tit <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal , <br /> Distance to nearest: Well Foundation Property Line <br /> 7. <br /> LEACHING LINE ❑ No. b Length of lines I length/size14� <br /> { FILTER BED ❑ Distance to nearest: Well Foundation Lina <br /> SEEPAGE PITS It Depth Size 1 Number r:w <br /> SUPS LI Distance io nearest:-,T Well Fo'undation Property Line <br /> DI <br /> kk <br /> I SPOSAL PONDS ❑M <br /> f I hereby certify that I,heve prepared this application and that the work will be done in accordance with San Joaquin couhty ordinances, state laws, and: <br /> � ,�rules-andragulations-of-ttte'San";Jo�quill'Cainty""""`-"'' '� - - °"'•`•�- rte- <br /> I 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, 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 sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." j <br /> The spplican Cal or all row omplete drawing on reverse side. <br /> Signed Title: tft Date: � 3 - <br /> %R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area N <br /> Pit or Vt Inspection by Date Fina) Inspection'by. <br /> LAdditional Comments: <br /> ­t­-AppIican tr Return�a]k-cbpY to San JOsgllinTCourity�PuDlic Health' erv`i sem'' 'y�' ` '�''"" " <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 952or- + <br /> INF�O�qq AMOUNT DUE AMOUNT REMITTED CASH sAECfIVED BY DATE PERM17NO. <br /> . EH1•.2y 3-24 IRfV,I/R5l <br /> EH t �!w 0 X,� 3 f a-a "5e r3 r25�i <br />