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APPLICATION FOR PERMIT <br /> - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> b �. 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> h <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 trade 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 _.r_a:271 X-2 l�iCv� t City C Lot Size/Acreage <br /> Owner's Name /f�� S it Address ► r A- L O K 224— 0/0s Phone tf <br /> Contractor License NS' 7 Phonlt <br /> "r `S � <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well D <br /> N r <br /> PUMP INSTALLATiO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES , 1762 DISPOSAL FLD. PROP. LINE <br /> � - - - FOUNDATION. = --•AGRICULTUPE-WEUII -'OTHER WEL PITSYSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> E) Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation—Z—Ef Dia. of Well Casing r <br /> >1 Qomsstic/Private ravel Pack 0 Tracy Type of Casing_ TPy�^ __ Specifications <br /> I'I Public 11 Others fl Delta Depth of Grout Seal Z77V 45 -2�Type of Grout <br /> I I IffigationA�p� ib. Depth I I Eastern Surface Seal Installed by�/�1,�C�f�r�.•r��r K <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth{ <br /> i Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Z3 <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number,of bedrooms . T <br /> Charactar'of soil to a depth of 3 feet: Water AW <br /> SEPTIC TANK. ❑ Type/Mfg ,Capacity No. Co <br /> 7 ED <br /> PKG. TREATMENT PLT,❑ Method oVE <br /> ��Jsposa]_ <br /> Distance to nearest: Well Foundation Property Line <br /> z IN COUNTY <br /> LEACHING LINE ❑ No. 11 Length of linesTotal Iengih/sinpl 811I-I AST <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prop",XIQNMI <br /> SEEPAGE PITS I 1 Depth Size Numbar <br /> SUMPS LI Distance to nearest: Well Foundation—'Property Line <br /> -DIS POSAt-PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wiii-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 $hall 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 compenss <br /> tion laws of California." <br /> The applicant must call for all required inspgctions. Complete drawing [►onreverse <br /> //side, <br /> Signed T Title: cLr/rn Dater � � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Datew Area <br /> ` � r <br /> Pito Grout I n b Date Find Inspection by <br /> apeCtloData <br /> Additional Comments: <br /> Applicant - Retur all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2005, Stkn, OA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMtTTEO C 5 RECEIVED 13Y D TE PERMIT�IffNO�.i <br /> • EN 17.21[ntY.I Irtef 1 /l <br /> EN ta•ss �� It.C7� J cam/ <br />