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APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HE <br />ALTH SERVICES <br />fiNVIRONMTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 "OX 20091 STOCKTON, CA 95201 <br />P " IRES 1 YEA_A F <br />(Complete in Tr' 7 DATg� RD <br />Application is here 1P leate) <br />made to Sea Jo+quia Count <br />application ie made in c�liance y for a permit to construct <br />J and/or install the work herein described. <br />Joaquin County public health Services. with San oaquin County Ordinance No. 544 and 1$62 and <br />This <br />the Rules and Regulations of <br />San <br />Job Address � <br />City Lot Size/Acreage�t[ <br />Owner's Name <br />�Ey <br />•-�•�- _--__ __ Address�f�� L�o.t/Al2D/,y� <br />` <br />ContraCtor F � (A1�o D AddressZ-g" .r <br />TYPE OF WELLlPUMP: NEW WELL ❑ —License No. Phone ^ 3 <br />WELL REPLACEMENT r DESTRUCTION ❑Out of Service well <br />�^ PUMP INSTALLATION [] -..- •y. SYSTEM AEPAIR'L) -� <br />DISTANCE <br />O <br />_...- . <br />TO NEAREST: SEPTIC TANK OTHER G Monitoring well <br />---�� SEWER LINES w DISPOSAL FLO. <br />FOUNDATION AGRICULTURE WELL PROP. LINE <br />INTENDED USE OTHER WELL PITS/SUMPS <br />TYPE OF WELL PROBLEM AREA <br />n Industrial _ CONSTRUCTION SPECIFICATIONS <br />I] Open Bottom - O <br />Manteca Dia. of Welt Excavation <br />C.1 Domastic/Povate ❑ Gravel Pack❑ Tracy <br />Dia. of Well Casing <br />Tylye. <br />Cl Puof Casinblic (� Olher g` Specificationsfl Delta :.Y -w -Depth of .Grout Seal..:.. <br />i I Irrigation <br />_ <br />, Approx. Depth I I Eastern TYP+ of Grout <br />Surface Seul Installed by <br />Repair Work Done U Type of Pump <br />H.P. <br />WON Destruction O WON Diameter Sealing Materiali Depth State Work Dome w <br />Depth = Tiller Material`& Depth <br />TYPE OF SEPTIC WORK; NEW INSTALLLATION I I REPAIR/ADDITION>(1 DESTRUCTION I I (No septic <br />system permitted if public sewer is <br />InstallationwiJf serve: Residence I' available within 200 lace.! <br />Commercial <br />Other <br />Number of living units. _,__L Number of bedrooms <br />Character of loaf to a depth of 3 feet: <br />SEPTIC TANK. O Type/Mfg . E Water table depth <br />PKG. TREATMENT PLT. O- - C+Pacity� Pao, Compartments <br />Method of Disposal <br />Distance to nearest—WON � <br />Foundatbn <br />-. , - *�. . -_ .... -- Property Line ;. <br />LEACHING LINE <br />FILTER BED <br />❑n <br />No. & Length of fines — / / <br />Total length/size_ <br />Distance to nearest:. Well , D rFoundation ��,er ` - <br />Property Line <br />accri%ur YItS IR' Depth .-S' Sue 3 `r <br />SUMPS Number <br />Ll Distance to nearest: well' <br />DISPOSAL PONDS ❑ -1�-- Foundation _g / Property Lino <br />I hereby comity that I have prepared this application and that the work will be done in accordance wi <br />rules and regulations of the San Joaquin County th San Jo aquin county ordinances, state laws, and <br />Homo owner or licensed agent's signature oertifiea the and <br />"I certify that.in the performance of the work for which this permit is issued, I shall not <br />SMPIOY any person in such manner as to become subject to workman's compensmion laws of California." Contractor's hiring or sub -contracting signature <br />certifies saws of California." the following:ia." "I certify that an the performance of the work for <br />or which t <br />hit permit is issued, I shall employ persons subject to workman's compensa-__, <br />tion l _ <br />The applicant must Coll for all r <br />equi <br />red inspections. Complete drawing on reverse side. <br />Signed v "" <br />Title: Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by r ' <br />Pit or Grout I �� Date4��f <br />Inspection by Data ---_—moi Final Inspection by f <br />Date r <br />Additional ConxnOnts: <br />Applicant - Return all coplea to: San Joaquin County Public Health Services <br />Environmental Health P&rmit/Services <br />445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />FEE <br />i AMOUNT DUE AMOUNT REMITTED <br />INFO �_^ <br />RECEIVED 6Y I OATE <br />sa <br />