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P <br /> 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 95201 # <br /> PERMITEXPIRES 1 YEAR FROM DATE S <br /> I (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r �} <br /> Job Address ! =1 o a 4/ ov�J �� _ City i Lot Size/Acreage <br /> Owner's Name �C Address Phone <br /> Contractor - Address fid' - License No. <br /> VJ 40 S1 Phone <br /> TYPE OF WELL/PUMP: NEW WELL 13WELL AYPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ "'. SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open-Bottom ❑ Manteca `'mak , Dia_?, ell Exco�atpn =, Dia. of Well Casing <br /> F.1 Domestic/Private ❑ Gravel Pack " CL-Tracy Type of Casing_ Specifications <br /> Zl- <br /> Il Public 11 011ier L (-1 Dell ` a: Depth of Grout Seal Type of Grout <br /> I I Irrigation —.App(ox. Depth I I Eastern Surface Seal Installed by �. <br /> Repair Work Done 0 Type of Pump f H.P. State Work Oona O <br /> WellDestruction'""" ❑ Well Rismeter Searing Material i Depth <br /> Depth_ Piller Naterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION- DESTRUCTION l 1 {No septic system permilted 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 soli to a depth of 3 feet: t ='~' `- M-�F W81er table depth 1 <br /> SEPTIC TANK. ❑ Type/Mfg 4 hA '""CCrpaciiy_ .. .,1No:Compartments ) <br /> _".rte _•� <br /> PKG. TREATMENT PLT.❑ }Method of Disposal <br /> Distance to nearest: Well .: . Fouridation r property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/sire a 3 <br /> FILTER SED ❑ Distance to nearest: We11 Faundwion� / Property Line r <br /> SEEPAGE PITS 11 Depth 2 L�r Size Number k <br /> SUMPS 0 Distance to nearest: Well:Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I her cenify 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 11 for all required In ns. Complete drawing on reverse side. <br /> Sigma Title: Dalt%: i <br /> T7 <br /> FO D RTMEN USE ONLY <br /> Application Accepted by Date _ Area <br /> r Grout Itspection by `- Date Final Inspection by' rr "- mate <br /> Adationsl Commente:,k `. f <br /> —Applicant�- Retur-nra.1l a piee;;t0.;.. San J.oaquiq�Count_y Public Health_Services (-■h` <br /> Environmental Health Permit/Services 7�1' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 UUU <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 9y DATE PERMIT'NO. <br /> INFO ,yam <br /> a EN 13.24111EV.ItAa)5A9 � - 3 �3-03 <br /> EN 14.26 <br />