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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIICES ,;,k�,:.. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)469WQ,x�MENTAL HEALTH <br /> P-A--B9 989 STOCKTON, CA 95201�ERKT'SERVICE <br /> PERMIT EXPIRES 1 YEAR F%& DATE Io _8 PM 1: 33 <br /> (Complete in Triplicate) <br /> Application is hereby made to Son Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coa> lisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> yy� p� �j 7� <br /> 60M, ' 4§1 'r , ffC /I LE th y 1 Lo Lot Size/Acre e y 0 <br /> Job Address � City a8 <br /> 7% relJr <br /> Owner's Name ,0e IAIC Address f'D,fin /,/d���I _ 1/U. i��,P me 2a s C7 <br /> dd A <br /> �r�f .J'"1 ��� �Lic nese�. 6o _Phons��� <br /> Contractor ��* AAddress <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Nell C1 <br /> PUMP INSTALLATION YSTEM REPAIR ❑ OTHER //)Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK eA�� �__ Pl/LIN <br /> FOUNDATION GRI LL WELL /S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOPId <br /> 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exca ion Dia. of Well Casing <br /> Cl Domestic/Private `❑ ravel Pack 0 Tracy Type of Casing_ Specifications <br /> 1'1 Public Other fl Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation /lu,� .Approx. Depth I I Eastern Surface Seal Installed by -/1, <br /> Repair Work Done U Type of Pump H.P. State Work Done_ 1 <br /> Well Destruction Cl Well Diameter Sealing Material & Depth <br /> Depth ]Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( 1 DESTRUCTION I I INo septic system permitted if 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 soe to a depth of 3 feat: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of linea Total length/sire <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS TT —D+stancWto rtsaresi4. Well v Foundation -T-�_. Property Line <br /> 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 <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 /> 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all requir i s etions. Complete drawing on raver side <br /> Signed X Title: Date: <br /> lFOR DEPARTMENT USE ONLY <br /> Application Accepted by _6�+ Date .T Area �i . <br /> Pit or Grout Inspection by '` Date <br /> Final Inspection by Date >' <br /> Additional Comments; <br /> Applicant - Return all copies to: San Joaq County Public Healtv Services <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 S <br /> FEE <br /> CK I <br /> INFO AMOUNT DUE AMOUNT REMITTED r7(CASH�J(p /�CEIVED BY DATE <br /> �fPERMIIT NO. <br /> . EH 13.24 IIIEV.i i a w �� U �� !IU/1O /+r[ dr11 'T I <br /> EH 14.18 f <br />