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APPLICATION FOR PERMIT <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 />PERMIT EXPIRES 1 YEAR FROM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />zi,qg Tio en I-on I Lot Size/Acreage <br />Owner's Name Name gariaFr •DrisoLL..-- Address 83/45-A)/10 /la7'1 -514,e44iphone ;71cq-ltT1.-5-77 <br />ContractOr 7/1154hiffdiA/iit(e0C.Address P09t'y License No. Z 97171 Phone 7? --.3zF3 <br />TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT El DESTRUCTION Cl Out of Service Well 0 <br />0 PUMP INSTALLATION Cl SYSTEM REPAIR 0 OTHER 2,2- Monitoring Well ---‘ 5 ie.,' 1 ben-int:IS <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Li Industrial 0 Open Bottom Cl Manteca Dia. of Well Excavation Die. of Well Casing <br />El Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br />("1 Public rl Other El Delta Depth of Grout Seal Type of Grout <br />I I IrrooatoOn Approx. Depth I I Eastern Surface Seal Installed by _ <br />Repair Work Done 0 Type of Pump H.P. State Work Done <br />i <br />i Well Destruction 0 Well Diameter Sealing Material l Depth <br />Depth Filler Material ti Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence Commercial Other <br />Number of living units - Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. 0 Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE Cl No. & Length of lines Total length/size <br />FILTER BED 0 Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS 0 <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, 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 compensa- <br />tion laws of California." <br />c•Q <br />The a <br />Sig <br />st coar ions. Complete drawing on r verse side. <br />Title: <br />FOR DEPARTMENT USE ONLY <br />Appl. Accepted by Date 2 <br />Date: <br />Pit or Grout Inspection by Date <br /> <br />Final Inspection by <br /> <br />Additional Additional Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br />= 2 <br />FEE <br />INFO AMOUNT DUE AMOUNT REMITTED 64-4 <br />CASH RECEIVED BY DATE \'----___ Elej_L_All NO. <br />.77 V,(/ - <br />g\ <br />EM 13-24 (REV. 1 .$) <br />14.36 <br />&&c53(9' 'I