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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)468-3420 <br /> P 0 BO%.,2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 Y FR M D E I <br /> (Complete ifs Triplicate) <br /> L <br /> 4 <br /> to San Ru <br /> n Joaquin County for a permit to construct and/or inate, the work herein described. This <br /> Application is hereby <br /> 4 application is made in adepliance with San Joaquin County Ordinance No. 549 and 1962 and the les and Regulations of San <br /> Joaquin County Public Health Services. <br /> Address <br /> ar�V City Lot Size/Acreage <br /> Job <br /> jr-q (,f Address 1 �J `Phone <br /> Owner's Name tvZb <br /> Contracts <br /> ddress �'� License No. FYJfCc� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of service Well <br /> OTHER ❑ Monitoring Yell ❑ <br /> PUMP INSTALLATION SYSTEM REPAI _ <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 I �¢ SEWER LINES SPOSAL FLD. PROP. LINE /gam/ - <br /> FOUNDATION � AGRICULTURE WELL OTHER WELL gam— PITSISUMPS !► •F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 industrial ❑ Ope r • Specifications �- <br /> Domestic/Privateravel Pack ❑ Tracy Type of Casing <br /> i 11 zlm _ .Type of Grout <br /> I'I Public Cl OINH-Mp J� ❑ Delta Depth of Grout Seal <br /> I I Irrigation �2tuA oxo I 1 Eastern SUAFce. sled by <br /> Repair Work Done Ll Type of Pump H.P. —�� -_ tato Work Don 0.*/ t� <br /> . Well Destruction ❑ Well Diamett�w. <br /> Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I_F DESTRUCTION I I (No.septic <br /> available systl m permitted if ublic sewer is <br /> Installation will serve: Residence— Commercial Other W r <br /> Number of IMng units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Wafer 1ab.Ie depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. fli Length of lines ` Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation f 'Property Line I <br /> SEEPAGE PITS 11 Depth - Size Nuitrber"­ f� <br /> SUMPS- LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 4 I hereby certify that I have prepared this application and that the work will be done in accordance with'San Joaquirrcounty ordinances. erste laws, and <br /> rules_and regulations of the San Joaquin County 'i <br /> Hams owner latieansad apanfa signatiiro certifies the following:"I certify that in the-performance of the work for which this permit is issued, I shall not <br /> teinploy any person in-such manner.as to become sub " Contractor s hiring or sub contracting signature <br /> ject to workman's compensation laws of California. <br /> [ certifies the fo#owing.,,"I certify that,in.the performance of the work for which this permit is issued,I shall employ persons subject to workman's compenso <br /> f tion laws of California." <br /> The applicant I ' tions. Complete drawing on reveal side. <br /> Signed X__o:!LT1 <br /> Title Date: <br /> 4 OR DEPARTMENT,USE ONLY <br /> c- �J1w.` �M � • ' Date. Area �.. L <br /> Application Accepted by - ... <br /> • •-- <br /> Pit or Grout Inspection by Date Z Final Inspection'by Date l <br /> Additional Cb rMnt Cy Q q7 a <br /> Applicant - Return all c ies to: San Joaquin County public Health Ser ces <br /> Environmental'-He - /? ' <br /> 445 N Sea Joagiiin.'p d Box 2009, Stkn, CA 95201. ��f Q[ rl.CK# <br /> FEE AMOUNT DUfi AMOUNT REMITTEDK RECEIVED BY DATE' PfRMI O. !/G� <br /> [ 1 of � rf. <br /> . Ert13-24IIIEV,ItAs] PN O(7 - <br /> EN 14.26 <br /> VV Pf <br /> 9.A, &0 <br />