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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 /> PER3dIT UEIRES 1 YEAR PROM DATE ISUUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sam Joaquin County for a permit to construct and/or Install the vork herein described. This <br /> application is made In coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. , <br /> Job Address dacCity Lot Size/Acreage ■�_ <br /> C eA <br /> Owner's Name �� Address 7..244 AJ• ^/W4 L ec(, Phone r <br /> VContractof�_JP.�rJ?.- S kVI—Address License No. ?T45& - -Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION 20 <br /> ❑ Out of service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP 1R ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRIC LTURE WE OTHER WELL PITS/SUMPS <br /> INTENDED USE - TYPE Of WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> tw, <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy y of Casing Specifications <br /> M Public I. <br /> Other ❑ Delta Depth Grout Seal Type of Grout <br /> lrrigalion __Approx, Depth [] Eastern F' .Suriace Sa InsraNad by <br /> pair Work Done L3 Type of Pump H State Work Doneil Destruction O Well Diameter Sealing Material 4 Dept <br /> Depth Filler Meteriai i Depth <br /> YPE Of .SEPTIC WORK: NEW:INSTALLATION REPAIR/ADDITION it DESTRUCTION irl (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence A Commercial Other (� <br /> Number of living units: Number of bedrooms —I / \ <br /> Character of soil to a depth of 3 feet: 92QI PL^—r iI Water table depth <br /> SEPTIC TANK. X Type/Mfg 0,d5W.AA Capacity + No. Compartments <br /> PKG.,-TREATMENT PLT, C1 �. j�^/ Method of Dispolal L <br /> Distance to nearest: Well 1 foundation 4 D Property Line J0 (L\ <br /> LEACHING LINE CK No. B Length of lines . Total length/sire Q <br /> i _ <br /> FILTER BED ❑ Distance to nearest: Well Foundation :41Y Property Line <br />+ l <br /> SEEPAGE PITS Depth -____��.: Sire 4/� Number - p� <br /> SUMPS LI Distance to nearest: Welles L Foundation�' �r Property Line <br /> ' DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or Sub-coritrscting signature <br /> eanifies the following: "I certify that in the poriormance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of Californ <br /> i The applicant mus call f"r all squired inspections, Complete drawing on reverse side. <br /> Signed Title: _ �� ^ � ' -- Data. �d _/9' 5 <br /> TiMENT USE ONLY <br /> f Application Accepted by Date 0 a Area <br /> Pit or Grout Impaction by Data Final Inspection by Date <br /> Additional Comments: �lr� ��� /b aroIrn <br /> s <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 <br /> } FEE <br /> INFO MOUNT DUE AMOUN�TJ_REMIrT i t q CASH RECEIVES) BY PA/TE PERMIT'NO. <br /> Eli t3-24 1lIEV. /x 5l t ( V V <br /> � ENI ;4•20 r �/.C.l 7 <br />