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APPLICATI& FOR PERMIT <br /> jai ;_5 S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> _ ENVIRONMENTAL HEALTH DIVISION <br /> Ff P O BOX 2009, STOCKTON, CA 952 .,a ti <br /> (209) 468-3447 MAY 2 0 1991 <br /> 1P RNTT F PIKES YEAR PR9X DATE It$g ED ENVIRONMENTAL HEALTM <br /> (Complete in Triplicate) PRRMITVS,PRv1p,, <br /> Application is'hereby made to San Joaquin County foroa permit to construct and/or install the work herein described. This <br /> application in made in ccna liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulAtione of San t <br /> Joaquin County Public Health Services. <br /> 1,206 tAr -dn, L c.�r� City Lot Size/Acreage <br /> Job Address pp�� <br /> Owner's Name <br /> V�p ca Addressm-6 PM <br /> ' ..per{` <br /> Contractor Address 5�'`"��� License No. Phone A� <br /> I <br /> TYPE OF WEL /PUMP: INI EW WELL 0 WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well Cl <br /> N(N <br /> 51 STALLATi Q I kI� OTHER ❑ Monitoring WellDISTANWAR : SEP I TANK �f `f'F SEWER LINES _ - DkSPOS IZOP. LINE <br /> FOUNDATION s3r0� AGRICULTURE WELL>_5_0V_ OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation T Dia. of Well Casing <br /> CJ Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing_,_. Specifications <br /> M Public ("I Other p Delta Depth of Grout Seal Type of Grout <br /> C1 Irrigation Approx. Depth C) Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P, St to Vyprk D ne N <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth —AWl <br /> Depth Filler Material 1, Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADOITION 0 DESTRUCTION 1:1 (No septic system permitted if public sewer is <br /> vailabla within 200 few.) <br /> Insta ' n will serve: Residence Commercial Other <br /> Number of i ' units: Numbs bedrooms <br /> hofaotef of soil to pth of 3 feet: Water t e depth <br /> SE T ANK. ❑ /Mfg opacity No. Compa nts <br /> PKG. TREA ENT PLT, Cl thod of Dispos <br /> Distance to est: Well Foundation Property Lin <br /> LEACHIN ❑ & Length of lines Total length/sit <br /> FIL R BED C 1 rs reel: foundation Property Line <br /> SEE 5 I I depth Sire Numb ._�.._ <br /> SUMPS Distance to nearest: I atlo Prop ray Line <br />.DISPOSAL"P_OND .: ❑- \ <br /> I hereby certify that I have prepared this application and that the worts 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; "t certify that in the performance at the work for which this permit is issued, l shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 'ons. Complete drawing a de, <br /> Oats: <br /> Signe --- <br /> a r-Cyl"��iL�(ORIMRTMENT USE ONLY 3 <br /> Application Accepted by ...'I-" Date Area <br /> Pit or Grout Inspection by Date 6' ~!/ Final Inspection by Date <br /> Additional Comments: <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 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK if RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . t:H,3.1.IREV.,,wel Sg C6 1 ' r ,�_j .a tn{`I i I <br /> 5X I <br /> EH,42a <br />