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APPLICATION FOR PERMIT <br /> SAN YAQU IN COUNTY PUBLIC HEALTH SE(MA CES <br /> 4 <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> P O BOX 2049, STOCKTON, CA 95201 <br /> (209) 468-3447 f <br /> PERMIT IRE, 1 YEAR I?R >>d DAT9 ISSUED <br /> (Complete - in ;Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance 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 S e".1 '``"' City ZrLot Size/Acreage fi 3 <br /> Owner's Name ...��'` m r�-rt,d Q°+����"^ Address /17 53 Ca Phone <br /> Contractor Address 7,1?zt License No. lz�g Phone GS Z. <br /> TYPE OF WELL/PUMP: NEW WELLOK WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK S 7D r `SEWER LINES r DISPOSAL ;L0,'­70' PROP. LINE Y2-r <br /> FOUNDATION Sar AGRICULTURE WELL OTHER WELL_>_ ' PITSISUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation =IO Dia. of Well Casing Y <br /> Cl Domestic/Private %Gravel Pack 0 Tracy Type of Casing 4/0 Sit`, gb010 CG Specifications <br /> M Public C] Other G Delta Depth of Grout Seat ae Type of Grout <br /> M lmoation �AoproR. Depth ❑ Eastern SurfaceiSeul Installed by S GU <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> yet 6 l Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIRIADOITiON M: DESTRUCTION CJ (No septic system permitted if public sewer is <br /> available within 200 feet - i <br /> tnstsaation will serve: Residence ^ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water tabte'depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.-Compartments 0 <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> a <br /> Distance to nearest: Well Foundation Property Line <br /> Ii + <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size- <br /> FILTER SED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line j <br /> DISPOSAL PONDS ❑ <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 <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. I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature. <br /> certifies the following:"I certity 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 applie t ust call for all rgquired inspections. Complete drawing on reverse side. <br /> Signed Title: Date, <br /> IR TMENT USE ONLY <br /> Applicar' Accepted by Date w — l Area 3 <br /> Pit or Grourinspection�by� �� Data �'� Final inspection by Date <br /> Additional Comments- _ <br /> Applicant — Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISI6H PERMIT/SERVICES �] <br /> 445 N SAN JOAQUIH, P 0 BOX 2009, STLCKTON, CA 85201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEwD�.� CASH; RECEIVED t3Y DATE �+ gPERMIT'No. <br /> EN 13.34 iREV,r/Asp <br /> ex� <br /> EK:4-26 v <br /> r <br /> 4 II <br />