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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 <br /> P O BOX 2009, STOCKTON, CA 9520) <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> j <br /> Appl cation is hereby made,to San Joaquin County for a permit to construct and/or install the work.herein described. This <br /> l application ie made in ce�liance with San Joaquin CountyfOrdinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> f z <br /> Job Address City Lot Size/Acreage <br /> Orr -- LL ,45pl n Po wr-e Gey <br /> wner's Name C �r�G`� �0 - Address r� Phone <br /> I ` v License No. �'aLa _Phone <br /> 667 <br /> Contractor Address <br /> ` ITYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION CI Out of Service Well Cl <br /> PUMP INSTALLATION O , SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> [3Well <br /> DISTAIJCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE L;Ll:! <br /> FOUNDATION �"'^" AGRICULTURE WELL '"`� OTHER WELL PiT5l.SUMP_S_�, '- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S l/ <br /> L-1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ G' Specifications CJ <br /> �I'I Public ; i-1 Other n Delta Depth of Grout Seal _ -- Type of Grout n <br /> I i Irrigation 1-20pprox. Depth 74astarn Surface Seal Installed by Q rest a J" <br /> �Repsr Work Done U Type of Pump H.P. State Work Done - <br /> .Well Destruction O Well Diameter Sealing Material i Depth <br /> r I Depth Filler Material i Depth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I-REPAIR IN D VON I-1--DESYFYUCTION i I (No septic system permitted if public sewer is <br /> available within 200 lost.) <br /> Installation wifl serve: Residence— Commercial— Other - <br /> i Number of living units: Number of bedrooms <br /> z Character of soil to a depth of 3 feet: T ?` Water table depth, <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartrnerits <br /> PKG TREATMENT PLT. Cl - Method of �ipos l ' <br /> i Distance to nearest: Well Foundation Property tine ULU 4 1992 <br /> LEACHING LINE 0 No.'& Length of linea Total length/size ; P° � ;t Ccri+" <br /> . ! <br /> FILTER BED Ci Distance to nearest: Well Foundation Property Lille: <br /> i m <br /> ?SEEPAGE PITS 11 Depth Size Number <br /> SUMPS•- Ll Distance to nearest: 3 Well ..Foundation Property Line <br /> 4.DISPOSAL PONDS <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 r <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 /> ampioy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> !certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compansa- <br /> 'tion laws of California." , <br /> ,The applicant t c f ON roqyirjw inspections. Complete drawing on re_rse side. <br /> Signed <br /> Title- Date: <br /> F ( FOR DEPARTMENT_USE. Y- � t} <br /> p 04 <br /> Application Accepted by - Date Area <br /> ;Pit or Grout Inspection by Data Final Inspection by - _ Date <br /> Additional Comment& - -- Zvi- - -A3ZIMIAMId <br /> Appl'cant Return a 1 copies to: San Joaquin County Public Health Services t �wt/Y1{ fif/ <br /> IF [[ pp,�� 1� Environmental Health Permit/Services ,8 <br /> L� NrFEEAMOVNT <br /> ���� 445 R San Joaquin,'P 0 Box 2009, Btkn, CA 952{)1 "�`V <br /> DUE AMOUNT REMITTED CRECEIVED BY DATE PERMIT'NO. <br /> 9 CASHEH 15-24 1aEV.1/4 5 /r U i ,S �RE P� ZA <br /> t H 14.20 <br />