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APPLICATION FOR PERMIT �I(� <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 /> PMIT EXPIRES I YEAR FROM DATE S <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 compliance vith San Joaquin County Ordinance No, 549 and 1662 and the Rules and Regulstiana of San <br /> Joaquin County Public Health Services. <br /> ' i <br /> Job Address 2 6 2 0,2 E City$SCALON — Lot Size/Acreage <br /> Owner's Name TERRY GULMON Address 26202 E MAGNOLIA phone 838—7 1 <br /> 3 0 <br /> CJrfh1tWLMM1 PUMPS, IW. Address 502 nuxM. License No.276660 Phone529-2020 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES - -DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specificat'ana <br /> l'I Publiti <br /> f:i Other C1 Delta Depth of Grout Sealj <br /> l I ation TYpa of Grout_ <br /> ler <br /> K? _ _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of�Pump H.P. State Wark Done Zlllfl] al <br /> pgbMW <br /> Well Destruction ❑ Well Dii meter Sealing Material i Depth <br /> Depth T11ler Material ik Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic System permitted if public sewer is 1 <br /> available within 200 feet.) <br /> - Installation will serve: Residence"'—Commercial_. Other t <br /> 3 <br /> Number of living units: ' Number of bedrooms <br /> Character of sod to a depth of 3 fest: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity o } <br /> PKG. TREATMENT PLT. ❑ i t <br /> et <br /> . �. Distance to nearest: Well Foundation properW, + <br /> Uih1 I jt'�.TY <br /> LEACHING LINE 0 No. di Length of lines Total tenKgz", HEAD -.. '`-' ` <br /> FILTER SED ❑ Distance to nearest: Wall Foundation _ �;V17di' t<�'�i-r " <br /> d <br /> SEEPAGE PITS I I Depth Site Number <br /> Ll to nearest: Well Foundation 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 l <br /> Howie 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 comp, <br /> tion laws of California." <br /> The applicant t all 7forl,aqui, in S. Complete drawing an r versa :ids. <br /> Signed Title: k <br /> Date: <br /> R DEP ONLY <br /> Application Accepted by _ Date 6 -Z ae, a <br /> Ph or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: "r <br /> Applicant '- Return all copies to:. San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> ti 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED <br /> INFO RE IVEp BY DATE PERMIT"ND. <br /> EN M24(REV.ries!EN 14.26 <br /> sr 1 <br /> a <br />