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APPLICATION fOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION OL� Lp 0 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERI[ T E%P I RES 1 YEAR FROM DATE ISSUEP ; <br /> (Complete in %riplicate) <br /> _ a <br /> Application349 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i gJob�',Addiess /J <br /> r - City Lot Size/Acreage /7czl:� <br /> Awnor's Nartro , (y'Di� - Address'"" /�''t" Phone ag p <br /> tCro"ntractor Address77 License N6.'/� 356 Phone �31 <br /> TYPE OF WELL/PUMP: -r NEW WELL ❑ WELL REPLAC59ENT C] DESTRUCTION"❑ Out`of"Servi'ce-Vell ❑ <br /> i <br /> PUMP INSTALLATION i <br /> ESOTHER.. Jell ❑DISTANCE TO NEAREST:-SEPTIC TANK LI <br /> DISPOSAL�FLD. PROP. LINE <br /> FOUNDATION A RICULTURE LL OTHER WELL PITS/SUMPS " <br /> INTENDED USE TYPE OF WELL PROBLEM A A C STRUCTION SPECIFICATIONS �` r <br /> Ll Industrial Q Open Bottom ❑ Manteca ia. of Wefl Excavation <br /> Dia. of.Well Casing n �, <br /> is Domestic/Private ❑ Gravel Pack 0 Tracy of Casing-- <br /> . <br /> tf( I <br /> 9- Spei:ifications. U <br /> I'1 Public ('7 Oilier L n Delta Dep of Grout Seal `"Type of Grout. <br /> 11 Irrigation Approx. Depth `I I Eastern Surface sei Installed by <br /> Repair Work Done ❑ Type of Pump H-P• <br /> State Work-Done r <br /> WaH'pestruetion O Well Diameter Seeing Material a Depth Q <br /> Depth Filler Material a Depth J� I <br /> TYPE'OF;SE.PTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic"system permitted if public sewer is <br /> available within-200 feel.) <br /> t <br /> Installation will serve: Residenci Commercial Other" <br /> Number of living units: Number of bedrooms ,'` <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK (' rJ <br /> Type/Mfg H Capacity C2 No. Compartments <br /> PKG. TREATMENT PLT.❑ 4 Method of Disposal <br /> AV :::E <br /> Distance to nearest: "`Well Foundation <br /> ; P rty Line <br /> i <br /> LEACHING LINE No. & Length of"lines Totpl iengih/size ZeJ /f Z <br /> A I r <br /> FILTER BED ,'p Distance to nearest: well .Foundation _ Property,Line�#`S._ <br /> _ e <br /> SEEPA6jF�JjS"X Depth,J" /�� t <br /> i:a Number <br /> SUMPS Ul Distance to nearest: We I:I � d � � <br /> -� Foundation�-- „ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l.have prepared this application,and thai the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> s and=regulation orthe San Joaquin_County O <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for-Wv ich this permit is issued, I shall not <br /> r 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, f shall smploy persons subject to workman's compensa- <br /> tion laws 61-Cilifomla." <br /> The applicant must tali for all required"in''spect'ton . Complete drawing on reverse side. <br /> Title:lgned _ - x. k t A4,6:7- Date: <br /> VVVvV w� F <br /> 4���FO DEPARTMEN�USE ONLY <br /> Application Accepted by Data 12 Area Z i <br /> Or Grout 1 y Data <br /> Inspection b Final Inspection by Date <br /> Additional,Comments: '" .• <br /> Applicant - Return all Copies to: San Joaquin County Public Health Services <br /> " 4 yP Envlronmer4ZI—Health permit/Services <br /> 445 N San..13osquin, P 0 Box 2009, Stkn, CA 95201 <br /> JFEE AMOUNT DUES AMOUNT REMiTTEO F. RECEIVED BY GATE PERMIT NO. <br /> °1CAAST♦ <br />• EH 13-t4IaEV.,/n41r t D{� dEH ll-3a 1 2 -5z 9Z-3953 <br />