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APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3.420 <br />P O BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made tSa <br />o n Joaquin County for a permit to construct and/or install the work herein deacribed. This <br />application is made in cottpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Servviicea. % �� , r <br />JoD Address t i L_ , -- l City 772 C Lot Size/Acreage / o 4v <br />Owners Name ? �1�.� Add,., � f� ^� Lyf� `Phone <br />kconttactor v WA-Ie" ---- Address __ � License No. � _ Phone <br />PE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well D <br />PUMP INSTALLATION.0 SYSTEM REPAIfIZ ❑ OTHER 0 Monitoring Well C] <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br />FOUNDATION AGRICULTURE WELL Z OTHER WELL PITS/SUMPS _ <br />INTENDED USE <br />Il Industrial <br />rl Domesticipfivam <br />I'1 Public-= - ' <br />I i lerrgation, <br />Repair Worts Done U <br />Wed, Destruction ❑ <br />TYPE OF WELL <br />PROBLEM API -r: <br />❑ Open Bottom <br />❑Manteca' <br />CI Gravel Pack <br />❑ Tracy <br />r Other <br />f7 Delta <br />_,.Approx. Depth <br />I I Eastern <br />Type of Pump <br />H.P-% <br />Well Diameter <br />Depen <br />WORK: NEW INSTALLA <br />3&TION SPECIFICATIONS <br />n wen txcavatron <br />of Casing <br />of Grout Seal <br />Saul Installed by <br />State Work Done _ <br />PEaling Material &,Dept <br />Tiller Material i Depth <br />Oia. of Well Casing <br />Specifications <br />- Type of Grout <br />REPAIR/ADDITION A DESTRUCTION I I LNG Septic System permitted if public sewer is <br />available within 200 feet. ) <br />Installation will serve_ Residence �__ Commercial ! Other <br />Number of living.units: Number of beorooms.. t <br />Character of sari to a depth of 3 feet: Water table depth <br />SEPTIC TANK $ Typt:/Mfg i r �- Capacity Z a �o N.. Compartments <br />PKG. TREATMENT'PLT. O Method of D' sal <br />Distance to nearest: Weiw foundation ? - Property Line _ <br />LEACHING LINE O No. b Length of lines a C ," 3 --76, Total length/sine �fb <br />FILTER BED 0 Distance tonVrest. Well 4�5• tV" Foundation Property Line S <br />SEEPAGE PITS I I Depth Si -Te ` <br />Number <br />SUMPS LI Distance w nearest: Well Foundilion: Property Lits. <br />ISPOSAL PONDS 0 :a <br />I hereby certify that I have prepared this application and that she work will be done'iri accordance with San Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin County - <br />Home owner to fic-411d spent': agneture certifies the following: "I ceriity that In the performance of .the work tor which this permit is issued, I shelf not <br />"bY any person in Stroh manner as to become subject to.workman'i compensation laws of California." Cohtractor's hiring or sub -contracting signature <br />certifies the (*dowing: "I cartify that in the performance of the work for vAich thispermit is�issued, <br />tion laws oftit la " 1 shall employ persons subject to workman's comtrensa- <br />, _ <br />The applies t mu MI f ad" <br />tAqulrs"d ins ti&W. CaMplete drawing on averse s' <br />_ <br />` S Title: yy 1 <br />b Date: <br /><7-- EPARTMENT,USE ONLY (gyp <br />App&ation Accepted by Ares -0� C <br />Pit or Grout I <br />napaction by Data Final Inspection by Date <br />Addhionial Comments: 70 <br />Applicant - Return all copiea to: San Joaquin County Public Healtb Services C51d �cc <br />Environmental Health permit/Services - <br />-- 445 N San Joaquin, P d Box 2009, Stan, CA 95201 t( <br />FEE <br />INFO �*1"T DUE AMOUNT REMITTED <br />_ <br />. EH 15-1 IRtY. o i M a <br />EN 14-26 <br />BY ! PATE I PERMil'NO. <br />