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APPLICATION FOR PERMIT <br /> *r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON$ CA 95201 <br /> (209) 468-3447 <br /> YEAR FM PA19 JgSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the cork 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 /> Job Address 9212 City SZ?jL&=A1 Lot size/Acreage <br /> Owner's Name .LuLV 1,4IV1}UC'C_/ _ Address A1AS5AIVQ D211J5 6UMMAe 513LILN2i <br /> Contractor_ �.�(� 4Qj9J4419vs,r Address kense No. Pfione — r72 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION t of Service Well ❑ j <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIiS/SUMP$ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing- -- Specifications <br /> M Public is Other C] Delta Depth of-Grout SealY� Type of Grout <br /> M IrriUation Approx. Depth C] Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump State Work Done oe <br /> Welt Destruction Well Diameter l.VC Sealing Material fr Depth <br /> Depth 70 IM Filler Material'& Depth l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIRIADOITION CI 'DESTRUCTION Cl .{ System permitted if public sewer ie <br /> n 200 feat.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of$oil to a depth of 3 feet: r / 'Wats) t <br /> SEPTIC TANK ❑ Type/Mfg Capacity �C�nRAM <br /> PKG. TREATMENT PLT.❑ / 1d17Dleoos <br /> Distance to nearest: Well Foundation PropsNO <br /> LEACHING LINE ❑ No. S Length of lines Total length/sire tfs LI <br /> FILTER BED ❑ Distance to nearest: Well foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number �j <br /> SUMPS LI 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, state laws, and <br /> rules and regulations of the San Joaquin County r <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 work mans compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I c ify 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 applit st I f r_jA req tr d inspections. Complete drawing on r rse sid1p, _. /� <br /> Signed Title: r Date: � f/ <br /> FOR DEPARTMENT USE ONLY C� <br /> Application Accepted by Date &E~! Area <br /> Pit or Grout Inspection by Date Final Inspection by Date I d <br /> Additional Comments: { l <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13.24 PIEV.iin5i Li <br />