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sir y <br /> APPLICATION FOR PERMIT it <br /> - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I ROI'MENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> R rft�& DAT 3—MMM <br /> (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> Application is herebynmadee,,toaSea�vithuSanCJoaquinoCounr a pY Ordinancermit to nlioru5a9ct aand o18628and the eRules aadeRegulationsof Ban <br /> a <br /> application is mad <br /> Joaquin County Public Health Services. <br /> City Lot. Size/Acreage <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name T <br /> License No. P <br /> Contractor �S Address <br /> hone <br /> WELL REPLACEMENT _JOESTRUCTfON ❑ Wt of Service Wall 0 <br /> TYPE OF WELL/PUMP. N W WEL ) 07NER C7 Monitoring Well U <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ �� <br /> �~ DISPOSAL FLD, PROP. LINE �® <br /> SEWER LINES PITSISUMPS G-Q <br /> DISTANCE TO NEAREST; SEPTIC TANK AGRICULTURE ' THER WELL-� <br /> u FOUNDATION �� j 1 <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION dila of WWell Casing <br /> INTENDED USE ❑ Mane--— <br /> �__ .p open Die. of Well Excavation <br /> E� Industrial TYRIf 9%, Casing Specifications <br /> i �pomesuc/Private ravel Pack ❑ Tracy Type of Grout <br /> ! til Other '© Delta Depth of Grout Seal <br /> M Public (1 <br /> Surface Sedl Installed by ML <br /> Cl irrigation cdLlApprox. Depth. rn <br /> H P State Work Dona <br /> .�, Repair Work Done U Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Wel! Diameter . Filler Material 4 Depth q's DepthPTlC WORK: NEWINSTALLATIONL1 RENo se <br /> PAIR/ADDITION CI DSTRUCTIgN GI availablelwthin 20c system 0 los;Lilp,,bl <br /> stallation will serve: Residence CommercialOtherw Number of bedrooms _—._. <br /> Numbsr�, f living units:-_ Water table dept <br /> Character of soil 16-1 depth'of 3.feet: No. Compartmen <br /> 'SEPTIC TANK ❑ Type/Mfg Capacity� -- <br /> Method of Dispo <br /> PKG. TREATMENT PLT.0 Property Line <br /> Distance to nearest: Well Foundation �- <br /> Total length/size <br /> I LEACHING UNE 0 No. & Length of linesProperty Line <br /> — <br /> 1 FILTER BED ❑ Distance to nearest: Well <br /> Foundation ��— <br /> SEEPAGE PITS 11 Depth Size <br /> Number I <br /> SUMPS CI Distance to nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS 0 `"+ I <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 /> I rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following, "I certify that in the peaormance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as Io becoma subject to work man's,ccmpensation laws of California," Contractor's hiring or sub-contracting signature <br /> which this"permit issued, (shall employ persons subject to workman's compensa- <br /> certifies the following; "I certify that in the perlormancs of'the work for <br /> tion laws of California." I,l�f, w <br /> The applicant ca o e ins eta drawing on reyer e <br /> e: r Date: ST �� <br /> Signed .�,"'� y (l1- <br /> Y j�F DEPARTMENT USE ONLY 4 �i <br /> - = Date _ �CI7 O Area <br /> 6 <br /> Applicatio ccepted by Gc_-,*/'vp J���� 7 <br /> r r r Date E-'- �< <br /> Pit ofthal <br /> spection by,� hate F'nal lnspeCtioi byAddimments;~ ' <br /> T�.fr4R.c�� i wIv r^s huh �g G3, �`�a <br /> Applicant - Aetura all copies to: SAN JOAQUIN COUNTY PUHLIC'HSALTFI,SRRVIC88' Gj� fo I Pin`° C/ rs9'-2u5 OWN <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES' '*^ tiv -��� �� , S✓-fry.1C. ✓y� <br /> 445 N SAN JOAQUIN, P 0 SOX 2008, STOCKTON, CA 952P1 �� <br /> I <br /> NjgE AMOUNT REMITTED CK RECEIVED SY OATS PERMIT'NO. <br /> CASH ^3�EH 13.24(REV,I/M" _ ry U 2 <br /> EH 74,2E G <br />