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2 APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I (209) 468-3447 <br /> >RMIT IRF 1 YEAR LP (Complete in Triplicate) <br /> Application is hereby made to San`.foaquin County for a permit to construct and/or install the work herein described. This <br /> r 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 /> aCity Lot Size/Acreage <br /> S Ig <br /> Job Address -*i5,KAX_Z-.I_ <br /> k <br /> j Phone <br /> Owner's Name Address <br /> C t+dttbr � _ <br /> 4••r'Addres '- L`icense-f+lo � •Phon <br /> TYPE OF WELLlPUMP: `vNEW.VVELL.0 VYELL .REP.LACEMENT _ DESTRUCTION 0 Out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitoring Well <br /> D1STAN GE-Td'NEAR EST:`SEPTIC-TA`NK "�"'-""-5'E1NER-LIfVES <br /> ... -..�."".....RISPOSAL1FL"D"".`.... ...`_PROP:-LINE" ." <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..� <br /> lNTENAED USE TYPEO,F WELL PROBLEM AREA CONSTRUCTION,,SPECIFICATIONS <br /> 'n lndustrisl� ❑ Open Bottom © Manteca Dia. of Well Exc9vat>on Dia. of Well Casing <br /> .❑ DomesNblPrivate <br /> Ci Gravel Pack 0 Tracy Type of Casing Specifications <br /> Type of Grout. ! <br /> [�.Public - I.TOt-her ❑ <br /> Delta Depth of Grout Seal i <br /> Ej lrripStion z-• p�bx•�Depth ❑ Eastern -SZRalce Seal installed by <br />' Repair Work Donee U Type of Pump ^ H.P, State Work Done _ <br /> rr" r Sealing Material & Depth <br />' <br /> Well Destfuction ❑ .Well Diameter <br /> t be � PIller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ FiEPAIRIADDITION DESTRUCTION CI (No septic system permitted if public sewer is <br /> � a I, available within 200,fee i <br />+ r Ins(eftetitir►wiq`serve: Residence_,r.Commercial Other ' s <br /> t ^/ Number of living units: Number.,of bedrooms <br /> Character of soil to a depth of 3 teat:res -"`"'"-' 9 Water table depth" i <br /> .SEPTIC,TANK _S 0 Type/Mfg:' Capcity -t No. Compartments f <br /> PKG•_TREATMENT PLT, CI Method of. Disposal <br /> S Foundation Property Line <br /> X, Distance to nearest: Weil • <br /> LEACHING LINE . No. & Length of lines r `tel Ie gth/sire f <br /> FILTER BED n Distance to!nearest: WeMi -,Foundations_ Property Lina-Z - -- <br /> SEEPAGE PITS Depth _ -- Si Number ! <br /> r (,_ ` - <br /> a A SUMPS /LIQ Distance to nearest: Well , .^Foundation; �••Properly Line f, <br /> ,DISPOSAL PONDS O e ' <br /> ." I hereby cinity that I have prepared this application and that the work will be done in.accordance with"San Joaquin county ordinances, state laws, and <br /> k rules and regulations of the Sen Joaquin;County t, <br /> j Home ownef or licensed agent's signature ce A ifies the following: �'i certify that in-the performance of the work for-which this permit is issued, I shall not <br /> f[ employ any person in such manner as to become subject to workman's compensation laws of California. Contractor„'s hiring or subcontracting 6lgnatUfB <br /> eenifies the foltowinq-T'ceriify'thit in the performance of the work for which-this permit is issued I shall empioy persons subject to workman's compensa- <br /> I (ion laws of California." <br /> The applicant ust c II for all required in c ions. Compl a drawing.on reverse side: ! <br /> Si nsd4 -NJ <br /> Title: ?" Date: <br /> 1 OR FNI I ISE OINLY.-__.__ q �sy a <br /> Application Accepted by " _ _. Date, JL--`' ` -�-Area — 3L <br /> pp G <br /> Plt Grout Inspection b �`�`� ' _ Date r Final lnspeGtion bye? 1 �- Data �1 <br /> kl� t gr <br /> Additional Comments: Z ✓ <br /> Applicant •- Return all copies to:] SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ <br /> ENV IRONNENT•AL-HEALTH•-DIV+$•ION--PERIHT/SERVICL�S" <br /> 445 ,N SAN JOAQUIN, -P, 0 BOX 2009, STOCKTON, CA 95201 <br /> k FEE AMOUNT DUE AMOUNT REMITTED' CASH CKS RECEIVED BY DATE PERMIT NO. �r <br /> t INFO <br /> 2�117L� Id <br /> )- -1 19 t-b`� 0 <br /> \ i <br />