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I <br /> APPLICATION FOR PERMIT <br /> �•6 I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> A ENVIRONMENTAL HEALTH DIVISION <br /> `P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> .l . <br /> ikRQX DATE ISSUED <br /> (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 is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of-San <br /> Joaquin County Public Health Services. <br /> Job Address �✓ '`'e SX41e4 N EAJ'TV A�z City 45;'�yO4 Lot Size/Acrerige <br /> Owner's Nami 72E,Ja//S Intik tl,d P-7[�_ Address Y95 ����� s �" Phone _ 6 <br /> y t� <br /> Conlractor_,,,FL`�� _u1lZjg_D '- - Address . License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT CJ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION El -SYSTEM-AEPAIR-!0 OTHER ❑'y Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES. DISPOSAL FLD, PROP.LINE__' A + € <br /> FOUNDATION; AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL •PROBLEM AREA CONSTRUCTION SPECIFICATIONS l <br /> fl Industrial O Open Bottom 0'Manteca Dia. of Well Excavation Dia, of Well Casing rC1 1 <br /> U Domestic/Private 0 Gravel Packs 0 Tracy_. Type of Casing Specifications � •# <br /> M Public la Other D Datta } Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Depth ❑ Eastern ""Surface Seal Installed by <br /> Repair Work Done U TYPOL of Pump k.P. , - State Work Done <br /> Well Destruction O Well Diameter ' Sesling1Mserial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION M (No septic system permitted if public sewer is' � <br /> available within 200 feet.) t <br /> Installation will serve: Residencs-�,__11 Commercial_ Other ^-Number of living units: ---7- Number of bedrooms 2- " <br /> Character of wit to a depth of 3 feet: . _Cs Z_, 1 " Water table depth <br /> SEPTIC TANK ,. Type/Mfg j��', P�'� Capacity -/&e�211 -` Q.o Compartments Z <br /> PKG. TREATMENT PLT. 0 � r r Method of Disposal. t <br /> Distance totnearest: Well 16 L10- Foundation Property.Line <br /> LEACHING LINE No. & Length of lines eL-A�f Tota! length/size <br /> FILTER BED [:1 Distance to.nearest: , Well Foundation Property Line <br /> SEEPAGE PITS IbK Depth 2n:+ Siwe " Number r <br /> SUMPS CI Distance to nearest: Well Foundation O r Property Line 44W r _ <br /> DISPOSAL PONDS © :I <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, 1 shall not <br /> employ 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 follOwingr"l-certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The app licant <br /> -must <br /> call for all required inspeVios, Complete drawing on reverse side. <br /> Signed X < liC Title: .. - Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by - Date�.S'�7` 1 Areaoil <br /> - - - - <br /> I <br /> tditional <br /> Grout Inspection by Date FinaE Inspection by Date Comments: _ <br /> t <br /> Applicant - Return all copies to: 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 .N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAVE PERMIT'NO. <br /> . Etc A-26 LA Iixyi:4 <br /> EM 26 �. Ly t L.tom l 1 001'5- -2Zq1 191� I <br /> ) <br />