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APPLICATION FOR PERMIT s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 " <br /> PERMIT EXPIRE FROM DAME ISSM <br /> (Complete in Triplicate) , <br /> Application is hereby mads 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.•.Hialth`services. �f p/V a ss--1710 —O/ <br /> Job Address ^u5ru ____ City Lot Size/Acrcege <br /> Owners Name AddressrM J 1-111, � fT Phone <br /> Contractor 5 do Address S License No._ZgQZt3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION D Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK MQSEWEA LINES DISPOSAL FLO./9M PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f -- Dia. of Well Casing <br /> n Domestic/Private Gravel Pack )4 Tracy Type of Casing_ Specifications.. <br /> f'1 Public to Other fl Delta Depth of Grout Seal f/5D Typo of Grout <br /> Irrigation _-._Approx. Depth I I Eastern Surface Seal Installed by, <br /> r <br /> Repair Work Done v Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 13 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: .Residence— Commercial— Other (Q/� <br /> Number of living units: Number of bedrooms PAYMENT "1 <br /> Chwactm of will to a depth of 3 feet: Water t r <br /> SEPTIC TANK. O Typs/Mfg Capacity No.�Com <br /> PKG. TREATMENT PLT.0 Methoq pf•>A944 1993 <br /> Distance to nearest: Well Foundation Property jOAQWIN COUNTY <br /> PI IRI IC HFAI 1H SPRWCER <br /> LEACHING LINE ❑ No. b Length of lines Total lengtt'NVA [4 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to newest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 shell not <br /> employ any pwson in such manner as to become subject to workman's compensation laws of California•" Contractors hiring or sub-contracting signature <br /> certifies the following: "I cenify 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 st tali for all requir nspeptions. Co latedrawing on verse side. ' <br /> Signed Title: ti Date: ..) <br /> OR DEPAR ENT USE ONLY <br /> Application Accepted by Date Z Q- Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Data, Z 913 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, ' <br /> INFO PF <br /> . EH t�zi IIRtEY.1,Nst l� �7-� z 3 _a <br /> EH 14.96 <br />