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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4;—At <br /> ENVIRONUENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201V8.0V 2 ® <br /> (209) 468-3447 �'G JO'�QUl1992 <br /> �Nrrt� � H4�r <br /> (Complete in Triplicate) O�M��fITA(M a�1�r1C"5 <br /> AN 171- 3CO-07 L�lVISIOA1 <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 with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin CountyPublicPublic Health 9ervicea. LL- A,. <br /> Job Address 237 R CilY�tOCkfTGA) Lot Size/Acreage 5ACQE% <br /> Owner'$ Nim@ BUSK U CQ AUf.r"FRIG Address 2373 MA 1PoSA9,0 4n14- 7G 3S <br /> Phone <br /> Conlracto+O��g�RG ST uJ rzT ddress 2M QIt, 7-S7&7 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service We11 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR I-) OTHER <br /> �tir�tl '1µo torteg Well <br /> 1 t0 LT2S <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TANK ]�� SEWER LINES �6(?e DISPOSAL FLO.6� PROP. LINE �� <br /> FOUNDATION Al--�•-- AGRICULTURE WELL OTHER WELL 2-Qa:— PITS/SUMPS QC�nG <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation 00 Dia. of Well Casing <br /> <Oomeslic/Privale 0 Gravel Pack ❑ Tracy Type of Casing &A16 Specifications--&Z� <br /> M PublicOlhar ❑ Delta Depth of Grout Seal SoRl`.4CE Type of Grouter �s <br /> CJ trriijation qApprox. Depth ❑ Eastern Surface Soul Installed byCOIL)T12ACT+ <br /> Repair Work Done U Type of Pump H.P. State Work Done ._ <br /> Well Destruction O Well Diameter Sealing YAterial i Depth <br /> Depth Yiller Naterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIRIADDiTION M DESTRUCTION 0 (Wo septic syslem pefmiltad it public sewer is <br /> InsuAvailable within 200 loot.)llatipn will serve: Residence CommercisE� Other <br /> Number of living units: Number of bedrooms <br /> Charactor of soil to a depth of 3 toot: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity _- No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. a Length of lines Total langthlsixe <br /> FILTER BED CI Distance to nearest: Well Foundation Prapeny Line <br /> ~SEEPAGE PITS Ii Depth Size Nurnbor <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby cenify thsl 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 /> Hom@ owner or licensed agent's signature cenifies the following; "I conify.thal in the porlormance of the work for which this peimit is issuad, I shell 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 /> cenilies the following: "I canify that in the performance of th@ work for which this parmil is issued, l shall employ persons subject to workman's componsa• <br /> tion laws of Californla." <br /> The applican mus all f II requir d inspections. Comp lots drawing on reverse side. <br /> Signed Title: .O tl f7 Date: !�� 76.7fF�-- <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by Data �2- '(46 <br /> Pit <br /> Pit or Grout Ijtspeclion by Dat Final Inspection by Date <br /> . 1 <br /> Additional Commants: <br /> Applicant - Return all cop as to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (]0 <br /> EXVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 2 <br /> 445 N SAN-JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOVNT REMITTED <br /> INFO CA5>I RECEIVED Y GATE P5RM11'NO. <br /> EK 17.74.IItEY.rixtir�Q QCj �pI <br />