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ll <br /> II <br /> 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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM- DATE I SII <br /> (Complete in Triplicate) <br /> Application is hereby made-to San Joaquin County for a permit to construct and/or install the work herein described. This <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 County Public He th SeRvices. <br /> Job Address City 0A" Lot Size/Acreage <br /> i .53 df�f�li�4 Phone <br /> Owner's Name �` �"^�^^^�d-� Adt�ress <br /> ' Z8ZZ� <br /> 3Phonea'S �0 <br /> Contra rn Address �t� License No. f <br /> TYPE Of WELL/PUMP: NEW WELL Cl <br /> REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3MonitoringfYell C] I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial <br /> 0 Open Bottom 0 Manteca ='� Dia. of Well Excavation Dia. of Well Casing <br /> .IF,.}. <br /> 41 <br /> C.1 Domestic/Private ,r,,,' ❑:Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public f.1 Other fl Delta Depth of Grout Seal Type of Grout <br /> _ P <br /> I I Irrigation —.Approx. Depth I I Eastern _ Surface Seuf Installed by <br /> Repair Work Done 0 Type'of Pump H.P` -- - Statq Work Done_ [1 <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth t <br /> Depth biller Material i:Depth„ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION i I. DESTRUCTION l I (No septic system permitted if public sewer is Q <br /> available within 200 feet.) <br /> f Installation will serve: Residan Commercial LJ Oihe� _ <br /> i Number of living units: "Number of ms , <br /> Character of sore to i iMpth of 3 feet: -- Water labia depth <br /> SEPTIC TANK: - Type/Mfg A JA-'Scapacity n No. C partments <br /> pKGo- )tit MEI"T PLT.❑ i t / 4.. Method.of.Disposal <br /> Distance to nearest: Well Foundation ��` Property;Line <br /> l <br /> ''' yt? 'length/size= -2 <br /> LEACHING LINE � No. 8 Length of linea _� Total <br /> g FILTER BED ❑ Distance to nearest: <br /> Well (2 f Foundation 2-�6/ Property Line _.S <br /> SEEPAGE PITS Depth Size ,} Number 177 <br /> i <br /> SUMPS L1 Distance to nearest: Well'?l l)O/ Foundation w Property Line <br /> t DISPOSAL PONDS ❑ J <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 /> rules and regulations of the San Joaquin County <br /> Homs owner or licensed agent's'knature certifies the following:-"I certify that in the=performance of the work for which this permit is issued, [-shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ poisons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call for eq ired inspections. Complete drawing on reverse <br /> f{)si i. <br /> e <br /> Signed LL2=019Title: Date:- <br /> p <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _Date_ ! Area <br /> I "0r Grout Inspection by �`Dsfo-=5� Final Inspection by Onto+� <br /> Additional Comments: - <br /> r' Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> I II 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 W. <br /> } FEE AMOUNT DUE AMOUNT REMITTED I CA H RECEIVED BY DATE PERMrr-ND. <br /> { iN�F/O <br /> EM 14-20 <br /> EM 4-24ItIEV.I/nII! /V �� idCJ ��� �� J J �� ✓"� <br /> f <br />