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APPL.I CATI ON FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH AVICES <br /> RN V I RONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROY__DATE-_ 3SUED <br /> (Complete in Triplicate) <br /> Application is hereby made to ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publ[i�a Health 8ervioss. <br /> Job Address �b0r1 U i iE_2- h IN 6 by City _�f-��-�*3 Lot Size/Acreage <br /> Owner's Name Zq kiv Address Phone( d c <br /> aertS �'iPtac�PtZlr�f� b 38 � 5"1`'1' ( -� � ��01) <br /> Contractor 04FIL5 I t4N t- Address v ti 1 - C License No, ��2 Gf(, Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION, -Mt of Service heli ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> 14 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ,� AGRICULTURE WE OTHER WELL PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17.1 Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing__ c�� Specifications <br /> f'I Public I'1 0!", ��elta Depth of Grout Seal 6— �-y_.- ___ Type of Grout "02-T <br /> I I Irr;gaUOn .Approx. Dep1h I I Eastern Surface Seal Installed by S <br /> Repair Work Done L7 Type of Pump ' H,P, State Work one 0 <br /> eft Destn,c ' 0 Well Diameter <br /> J <br /> it Sealing Material & Depth P- 4&f-kJ-Th r-r 1 {f;� 0 <br /> 1 L <br /> Depth Filler Material i Depth I�ISS G �� Ct)s✓\PlcJ►.S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I iNo septic system perTitled if public sewer is <br /> available within 200 feet.! <br /> installation will serv*: Residence— Commercial_ Other X� <br /> Number of living units: Number of b*drooms <br /> Character of &all to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ClMethod of Disposal <br /> D ce to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to near Well Foundation Property Line <br /> ,r <br /> SEEPAGE PITS 11 Depth Sire r . Number <br /> SUMPS Lt Distance to Wean ell' Foundation Property Line <br /> DISPOSAL PONDS p <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 i <br /> Horne 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 shell not <br /> employ env person in such manner as to become subject toworkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of rhe work for which this permit is issued, I shall employ persons subject to workman'*compensa- <br /> tion laws of California." <br /> The applicsn must cell fo aR required inspections. Complete drawing on reverse side. <br /> i <br /> Sigma Title: _lrzR O� G(c,+7� _._ Date: r7 - (7.�Ct <br /> ,..�-, FORD PARTMEHT USE ONLY �� <br /> Application Accepted bya"I `' pate2L <br /> Area4A i <br /> Pit of Grout Inspection by Date Final inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services19��� � <br /> Environmental Health Permit Servlcee ! <br /> 445 N San Joaquin, P O Boer 2009, Stkn, CA 95201 <br /> FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED by OAT PERMIT'No. <br /> fH <br /> . Els 111-Nt <br /> ��ta {{ <br /> I <br />