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APPLICATION FOR �fiR.>C3�C� ALHEnTHDIVISION VICES <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH AL PERMIT <br /> ENVIRONMENTAL HEALTH DIVISIDN <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 . <br /> ,EMIT EXPIRES 1 YEAR rROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to Sea Joaquin County for a permit to construct and/or install the work herein described. Thie <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin Count Health Services. <br /> Job Address dS /� <br /> e, •`Cf. CilyJC41MW6,%0Lot Size/Acreage <br /> JOA 120.4!3c X Address �=r..svA,ys' Phone <br /> Owner's Nams-a <br /> Y Address & License No. _Phone 4 yam' 71 <br /> • <br /> Contractor - <br /> TYP€ OF WELL/PUMP: NEW WELL CC WELL REPLACEMENT Cl DESTRUCT{ON ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 13Monitoring well G7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ZCX.Q� SEWER LINES [/0eL'_* DISPOSAL FLD.Z!ZOO PROP. LINE>LQo" _- <br /> FOUNDATION lGQ ' AGRICULTURE WELL~l'AL*Af_ OTHER WELL: _000 ' PITS/SUMPS 2�96 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFiCATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Die, of Wall Excavation Dia. of Well Casing'M YF,yBo <br /> U Domestic/Private 19 Gravel Pack 0 Tracy Type of Casing VL Specifications <br /> X y�niiTdR- (;1 Other 0 Delta Depth of Grout Seal 4 Type of Grout <br /> M Irrigation ,�eApprox. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AODITIO 0 DESTRUCTION G (No septic system rmitted if public sewer is <br /> available within 2 feet.} <br /> Instatlatio will serve: Residence ommercial— Other <br /> Number of Ing units: Number bedrooms <br /> Character of it to a depth of 3 feat: Water table depth <br /> SEPTIC TANK O Type/Mfg Ca city No. Compartments <br /> PKG. TREATMENT LT.C7 Method of Disposal <br /> Distance to nearest. Well Foundation Property Line <br /> LEACHING LINENo. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: ell Foundation Property Line <br /> SEEPAGE PITS 1 ! De th Size N bar <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 Sen Joaquin County <br /> Home owner or licensed agent's signature eenifies the following: "I comity that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as-to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for wtoich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." r� oi,- PL,r4.i/ fv. �o4Y-r7o.frS <br /> The epplica call for all required ins tions. Complete drawing on��r�everse <br /> A-7, A r- /��,,, -+� — Date: <br /> Signed Title: _._I - <br /> FOFJ DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by ( Date i' Area <br /> Pit or Grout Inspection by ate �� Final Inspection by Date 3 " <br /> S��-i�ENVIRON]VYl . P f if 0 � # �,, p <br /> Applicant Return all apiee to: S IN COUNTY PUBLIC HEALTH SERVICES �i� '[ C, <br /> SPECI�I. PER �'�pAQOX HEALTH <br /> p ODIVISION <br /> 2008E PERMIT/SERVICES <br /> 85201 ���� sF <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> . EH 13.24 OREV.I/A5r <br /> EM ;�•2a i V <br />