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APPLICATION FOR PERMIT <br /> SAN J0 QUIN 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> Health Services. 7 <br /> Job Address 3 5 2_ IGE• 1,A 1 NJE� _. ..,. ,_....,,,,.....� City �� Lot Size/Acreage J <br /> Owner's Name _7Zll p0 I—P/—/ 1z AJ 7f_Jlti( Address vSEA RD Phones III' 41 <br /> Contractor Fj J)021.W _7��6CIZ_clL Address 39ZI X/ ZLEM924 License No. Phone l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION Cl Out of Service Well ❑ # <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 1 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE i <br /> I <br /> FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca ia. o ail Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca 199_ Specifications W <br /> I'1 Public C1 Other n Del Depth of Grout Seal Type of Grout n <br /> I I Irrigation —.Approx. Depth I astern 1 Surface Seal Installed by } <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth j <br /> i <br /> Depth Tiller Material i Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> , available within 200 feet.) T1 <br /> Installation will serve: Residence_ Commercial— Other r { Irl 1 <br /> Number of living units: Number of bedroomskD1 <br /> Character of soil Its a depth of 3 feat: MIT aEppaIrtments depth ` <br /> SEPTIC TANK. ❑ Type/Mfg Caipacity No. �7 <br /> PKG. TREATMENT PLT.0 Permit may have op red w%rir6riof Disposal �f <br /> Distance to nearest: Wellrk 6VII I�tFId � �r Mar <br /> LEACHING LINE Cl No. 6 Length of lines __ flvlronm-p l` -Nik •, f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance 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, stats laws, and <br /> rules and..• 4-ti-on nf._tha San_Joaquin_ County <br /> Home ov —�`�` " _`•^,--3rtify that in the performance of the work for which this p_ermit is issued, I shall not <br /> employ a r s compensation laws of California."Contractors hiring or subcontracting signature <br /> aertiftq I 1 1 t(�2^ yi c{ aNu r which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion lawn r <br /> The appyy <br /> p on rev rae side. -7 <br /> Data: ;2 <br /> ARTU NT USE ONLY <br /> Appltcat I--+oWcArr+,- Date y Area L� <br /> Pit,or G Final Inspection by Date <br /> Addiflor <br /> API )unty Public Health Services I <br /> Health Permit/Services <br /> juin, P O Box 2009, Stkn, CA 95201 <br /> CK A RECEIVED BY DATE PERMiT'NO <br /> CASH <br /> • EN 13.24 IREV i <br /> EH 14.2a t-6-7-J] 6!L 7&A z- <br />