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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468- 3q-P'O <br /> (Complete in Triplicate) ! <br /> Application 1a hereby made to San Joaquin County for a permit to construct and/or install the work berein described. This <br /> ayplleation is made in ccWliance with San Joaquin County Ordinance No. 549 s.nd 1862 and the Rules and Regulations of San <br /> Joaquin County public Healtb 8ervicss. <br /> KJob Address 4-5 1A . W I`V" 9 City •"'' Lot8lppse��/��A��ereage <br /> MCC— <br /> /\Owen's Name By u "D Address • ' „ ^_ Lf hone <br /> COnitaclaI� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION O Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O <br /> Monitoring Well C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom O Manteca Dis. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing _ _ _ Specifications <br /> Q Punic _ --I'I Omer-"�" 0� Delo�" -depth of Grout SesE t � Type of Grout <br /> C7 Irt*stion _.Approa. Depth ❑ Eastern L-I,"S?j&ce Slal Ins14I1vd_b3• <br /> ` — H.P. State Work Doe_ <br /> Repair Work Done U Type of Pump t <br /> Well Destruction Well�O Anti Material i Depth <br /> Tiller Material i Depth f <br /> \ Depth <br /> TYPE OF SEPTIC WORK- NEW'INSTALLATION 0 REPAIR/ADDITION C! OESTRUCTIOINo septic system permitted if public sewer is <br /> wailabla within 200 lost.) <br /> Installation Will serve: \idance_. Commercial Other } <br /> Number of living units: Number of bedrooms <br /> Character of 6011 to a)bpth o1`3 feet: 3 Water table depth <br /> SEPTIC TANK O Typi/.M1g Capacity No: Compartments <br /> PKG. TREATMENT PLT.CI\ <br /> Method of Disposal <br /> Distance to neeresi: W611 ��� , Foundation Property Lie <br /> LEACHING LINE ❑ No. 8'Length�'of linea-' Total length/size <br /> FILTER BED Cl Distance Nio nearest: Well Foundation Property Une <br /> SEEPAGE PITS 11 Depth \ Sim�iL t - Numbers <br /> SUMPS LI Distance to ri"s :- Won Foundation ,Property Line <br /> 'V,� ti <br /> DISPOSAL PONDS IDN 7 . <br /> I hereby certify that I hsys prepared this oppltcatich'and that the work will be done in accordance with San Joaquin county ordinances, state Laws, and <br /> rules and nguialions of the San Joaquin County �� <br /> Home owner or licanosd agent's signature certifies the following. "I certify that in hi performance o1 the work for which this permit is tuued.I shall not <br /> employ any person in such manner as to become @ubject.to woeltman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> cardiae:the following;"I unify that in the performanci ol,tKe_work for which•this permit is issued. 1 shall employ persons subject 10 workman's torn 4sa <br /> tion laws of CaliforNa." 4 :\/ <br /> he applior all requ mplete.dravAng on neveros side. <br /> ut, <br /> Tltli: Date: 3 <br /> Z- 1 -91 <br /> �Fl OEPARTMtAENT USE ONLY <br /> Area f <br /> �. <br /> Application Accepted by Data �w..t_A� <br /> Pit or Grout InaWtbn by Date Final Inspection by pats ro b <br /> Additional Comment@:• \ � \\ <br /> Applicant - Return 611 copies to: SAN JOAQUIN COUNTY PUBLIC NYIILTB SERVICES <br /> ENYIRONMEXTAL HEALTH DIVISION PBRMIT/3RRVIC88 <br /> i 445 N SAN JOAQUIN. P O BOX 2000; STOCXTON. CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT NEMIrrTV�TE�.O CK 2 CASH RCE1/!V)1ED BY r DATE9PERMIT NO. <br /> t . In 1374(Ally. n$t OO �� •W .3u 1 'M - d 43 <br /> Err:r•>r <br />