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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNLENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMITE%PIRES 1 YFM FROM DATE I S <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application in made in ccuPlisnce with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San i <br /> Joaquin County public Health Servi'{s. <br /> r7as -City ^* Lot Size/Acreage L = r a has91 <br /> Job Address i 45333 - <br /> ML <br /> t;`ItORSLtSa� •s Address _p.�•'�ax � <br /> � q3 S� _ Phone AMi <br /> Owner's Name IIA3 <br /> � l3 Ar <br /> ! I ense rio. Phone digit <br /> Contractor n �4OAddress <br /> WELL REPLACEMENT n OESTRUC I t of Servicewe23 ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT <br /> "�^+ PROP. LINE � <br /> SEWER LINES DISPOSAL FLD. - —. <br /> DISTANCE TO NEAREST: SEPTIC TANK �— -. .,��.�Y.;,,. �:� :�•�-s•��°�- � - ��"'PITS/5UMP5 F� <br /> FOUNDATION••` AGR1CUl TURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION"SPECIFICATIONS D� of WeU Casing <br /> L1 Industrial ❑ Open Bottom ❑ Manteca'-. "'bia. of Well Excavation — <br /> Type of Casing_ Specifications.. 1- i <br /> Cl Domestic/Private Cl Gravel Pack ❑ Tracy x Type of Grout Q � <br /> I.1 Public Cl Other, Cl Delta Depth of Grout Seal <br /> I I Irrigation Approx, Depth 1 1 Eastern Surface Seal installed by <br /> 1 <br /> Repair Work Done 0 Type of Pump H.P. J State Work Done_ } <br /> �, �Seril4ng�Matol-fal irDrpth-,.-------�•---�.-�'--t.'---'"--- �I <br /> Well Destruction ❑ "Well Diameter hiller Material i Depth l <br /> Depth O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADDITION 1 I DESTRUCTION 1NailabeErwi system <br /> 200 htt`ed if public sower is <br /> �. <br /> Installation will serve: Residence-— Commercial— Other <br /> Number of lining units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feat: <br /> SEPTIC TANK) ❑ Type/M1g Capacity No. Compartments <br /> Method of Disposal <br />{ PKG. TREATMENT PLT.❑ <br /> Distance to nearest-. Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/sire <br /> r <br /> FILTER BED i, ❑ Distance to nearest: Well Foundation Property Line 3 <br /> SEEPAGE PITS Ii Depth Sire_ Number <br /> f SUMPS - .�-TLl Distance to nearest: Well ,Foundation Property Line. s <br /> DISPOSAL PONDS ❑ <br /> { hat the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> I hereby certify that I have prepared this application and t <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, 1 shell 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 /> unifies the fogowi "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- <br /> j tion laws of Califon <br /> The applicant mu r req ' splkct Complete drawing reverse side. 1 <br /> Signed r Title: Data: <br /> FO EP TMENT S_E ONLY <br /> . Dots � � Area <br /> Application Accepted by <br /> }F, Pit or Grout Inspection by Date Final Inspection by Date <br /> ` e r <br /> yF Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> A <br /> 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 <br /> FEE CK RECEIVED BY HATE PERMIT'NO. <br /> INFO AMOUNT Dat AMOUNT REMITTED —CASH_�7 <br /> oA <br /> . EN 13-24IREV.ItA5�� 1 7 �� ✓_ / ys !3 <br /> 6 <br /> M 14.M <br />