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APPLICATION FOR PERWIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , p�f.,>tIL , <br /> I x(11 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, ° PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1_,R0 FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 4� <br /> Application is hereby made to San Joaquin County for a permit;to construct and/or install the vork 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 /> 4 <br /> Job Address. 7, Y " —ilego City'hlfK Lot Size/Acreage � lo?w <br /> �f� /�J r <br /> Owner's Name �wm►. All Address ! / / s" 4efl e Y 1�-t"3_�d`M fH hone "-5' <br /> Canlractbr /1S h <br /> * Address /19 411weC Ad Tl.�da-7 License No. Phone T <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C] DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER.;0 .Monitoring Well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK ._bD� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION Ze r AGRICULTURE WELL OTHER WELL PITS/SUMPS _. <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M...�. <br /> f <br /> 0 Industrial ❑ Open Bottom 0 Manteca Dia.,of Well Excavation Dia. of Well Casing 96 <br /> 1xpomestic/Private Xiravel Pack -0 Tracy Type of Casing_ Specifications <br /> Il Public I:1 Other fl Delta Depth of Grout Seal /�? F Type of Grout <br /> I I Irrigation � Approx. Depth I I Eastern Surfrce Seal Installed by�/�9 r�`lc <br /> Repair Work.Done 0 Type of Pump H.P. State Work Done <br /> WellDestruction O Well Diameter Sealing Materiel i Depth _ <br /> Depth P11ler Material h Depth <br /> i TYPE OF SEPTIC WORK:w,-NEW INSTALLATION I 1 REPAIR/ADDtTION,I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within-200 feet.),. .. M,. •„ <br /> Installation will serve: Residence— Commerciat_ Other- `7_ on <br /> I Number of living units: " Number of bedrooms <br /> ,f Character of soil to a depth of 3 feet: star table de <br /> SEPTIC TANK ❑ Type/Mfg 41 Capacity NoWa <br /> } PKG. TREATMENT PLT.❑ li J I M���f'W°tIIL <br /> Distance to nearest: Well Foundation Property 3�99 <br /> j �L UU �t��r.�+ <br /> LEACHING LINE CI No, 8 Length of lines ' Total length/15 IN(' <br /> FILTER BED 0 Distance to nearest: Well Foundation ProWEA L}�VjS�QN <br /> RONM <br /> SEEPAGE PITS I I Depth Size Number <br /> 5.. <br /> SUMPS LI .;Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C]:"" <br /> I'119 aby CO ifyf'1'I`h`aveprapared"� [ht piicatwn and.ihat the work will be done in accordance with San JoaQuin county ordinances, stets laws, ander <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed"ant's signature certifies the following: "I certify t1at in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mariner 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> The applicantCst call for all rsquir in tions. Complete drawing on reverse side. <br /> {Signed t f- Title: tr(l 1191A Data: " <br /> &IJAIIAt <br /> DEPARTMENT USE ONLYApplication Accepted by Date ] .0 I Area `--� 1 �t�il Pit or rout an by ``✓Date Final Inspection by ` Date <br /> Additional Comments: +tJJ <br /> Applicant - Return all pies to: San Joaquin County Public Health Services <br /> Envir445NOnmertto Health 0 Boot/Services <br /> 495 N Ban Joaquin, P O Box2009, Stkii, GA 95201 <br /> FEECKS <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT-ND. <br /> + EM tt,•36,REV.b y 6!i s+lir C J r't p� Cf '33` Y f)-m lS— 0 l <br />