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APPLICATION FOR PERMIT <br /> SAN_ JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ` V.. �. ; <br /> ' P O BOX 2009, STOCKTON CA 95201 Qc,f <br /> � AN� 13 <br /> PERMIT E%PIRES 1 YEAR FROM DAT_F. ISSU I -all©,q0C/1; ,1191q2 <br /> (Complete in Triplicate) C�r�lP✓� RI��R�T I ��1/T <br /> Application is hereby made.-to Baa Joaquin-County for a permit to construct and/or install. the work herein d c`f l�ea:S This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re tion IV <br /> Joaquin County Public Health Services. VIA <br /> w <br /> Job Address City Lot Size/Acreage <br /> t , x <br /> Ownef's Name • i Address �1 l t o u _) �&6_aa Phone 0� <br /> Contractor >R . ddressAl kem ` p <br /> License No, Vfr S 6Phone ¢ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n1 DESTRUCTION ❑ Dut of Service Well ❑ <br /> - ;PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 1 Monitoring Well ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES )DISPOSAL FLD. PROP. LINE { <br /> �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSV'� <br /> z Y <br /> C1 Industrial t❑ Open Bottom f ❑ Manteca Dia. of Well Excavation Dia. of;Well Casing <br /> �Domestic/Private t Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> rlPublic. ',Fl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seat installed by <br /> Repair Work Done 1,4JETyps of Pump H.P. — 199 State Work Done \J� <br /> Well Destruction; ❑ 4,WNI Diameter Sealing Material A Depth <br /> : iDepth Filler Material A Depth r L _ <br /> TYPE OF SEPTIC WORK:i NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted A public sewer is <br /> # £ - available within 200 feet.) <br /> Installation will serve: Residence, -Commercial— Other <br /> ' Number of living units: \Number of bedrooms <br /> _Character of tiob to a d pth of'3-feer. yyater tabledepth <br /> ' SEPTIC TANK. Q /Typa/Mfg Capacity No. Compartments <br /> PKG. TREATMENVPLT.C3 r <br /> � ✓ - Method of Disposal <br /> Distance to neaeast: Well Foundation Property Line <br /> LEACHING LINE ' -O No. 6'Length of IinesL Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prpperty Line ; <br /> SEEPAGE PITS/- I 1 Depth �f Sire i Number , <br /> SUMPS X11 Distance to rwarast: .. Well Foundation Property Line <br /> DISPOSAL PONDS -- .IDE 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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that-inihe.pertormance-of-the work for which this permit is issued, I shall not <br /> employ any person h manner as to become subject to`workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies,ths g: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons <br /> sons subject to workman's compensa- <br /> tion lawsi Calif <br /> The applicant t II for ail requir�n�spe.cfi�onornplete` drawing on or ids <br /> Signed XTitle: �rAAAA6 C-P I—)­ 16 - - 5 <br /> Date: <br /> f <br /> i <br /> FOR D ATM <br /> Application Accepted b 1 ! ate res <br /> Pit tN Grout Inspection by Date^ i Final Inspection by Date .r3--� Z <br /> Additional Comments: <br /> Applicant!- Return all copies to: San Joaqui Cdu Ly Pnbllc t3ealth 'Services <br /> Environmentaa4'Health Perm 't/Services �( t <br /> 445 N San Jo4� '�1�►1-' <br /> / quin, P Bo 2008, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED K R CEIVED BY DATE PERM17'No. <br />. EH13.24(REV.beet 1 / 6!��C �0/,/� t <br /> EM 114.26 .y <br /> JF <br /> Y <br />