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it <br /> APPLICATION FOR PERMIT I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Q ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, 3TOCgTON, CA 95201 APIA <br /> 1 <br /> (209) 468-3447 <br /> PER EXPIRRS 1 YEAR PH99 DATESMM <br /> (Complete in Triplicate) "'1 0 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the R a f San <br /> ' t�f , .AME��r r <br /> Joaquin County Public Health Services. €RMITISWICES <br /> ,fob Address <br /> NUrn�E City - - Lot Size/Acreage <br /> Owner's Name- 1j7LLS Address , Phone <br /> Contracto FG �i r dress ZS E. R'1Y/Z7Z f Z-T-. License No.S1ZZ(SB _ Phone <br /> I <br /> TYPE OF WELL/PUMP:'.` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Li <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. y 6 7&1- <br /> 1I FOUNDATION AGRICULTURE WELL OTHER WELL L2-i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 11�� • <br /> 11 Industrial i1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I <br /> + <br /> U Domestic/Private it ❑ Gravel Pack ❑ Tracy Type of Casing y5prcifiaatieRs <br /> M Public �: I.1 Other © Delta Depth of Grout Seal I pe-vh8rovt /ila W 4' <br /> 0 Irrigation �� Approx. Depth 0 Eastern Surface Seal Installed by �F 6d11 CtJur, itiifGL: <br /> Repair work pone (] ��` Type of Pump H,P. StM Wurk 001re�..._. <br /> 44 <br /> Well Destruction 0 Well Diameter Sealing ))steric) i Depth p <br /> If <br /> I <br /> If Depth Filler Material i Depth j <br /> TYPE OF SEPTIC WORK': MEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: [Residence Commercial_ Other <br /> Number of living unitsii Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK i❑ Type/Mfg Capacity No, Compartments <br /> PKG, TREATMENT PLT:IO Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. 8 Length of lines Total length/size <br /> FILTER BED In Distance to nearest: Well Foundation Property Line <br /> h <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 6 Distance to nearest: Well Foundation -- Property Line <br /> DISPOSAL PONDS ICJ <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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I 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: "l 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." T �I <br /> The applicant t call for uired inspections. Complete drawing on reverse side. <br /> Signed X Z�_- --_- -- _ Title: 6711-fr6- 4:ASjOL<061ST- <br /> -- Date: 16—�/--�! _ <br /> �I FOR DEPARTMENT USE ONLY <br /> Application Accepted Date �r �r�/ Area 7 <br /> Pit or Grout Inspection by _ Date Final Inspe tion by Date <br /> Additional Comments: h z d f �� _�/� a _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> iI 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CA HECEIVED BY DATE PERMIT'NO, <br /> EH 11741REV.ii�6) <br /> EH 144e 111 l 1 <br />