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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 /> (209) 468-547 64,P0 f <br /> PRRMTT R]JIRRa 1 YEAR PRO.PATE. iSSU , <br /> (Complete in Triplicate) t <br /> Application to hereby amde to Baa Joaquin County for a permit to construct and/or install the vorlt herein described. This <br /> application to wade in coWliance vith Ban Joaquin County Ordinance No. 549 and 1862 AM the Rules and Regulations of Ban <br /> Joaquin Cotutty Public Health Services. <br /> V— e ` . �r-o t Lot Bite/Acreage <br /> Job Address G �2-"oc� S �rCity <br /> Tr ;p►e IF Qc'cc�y. '- L :�r� Phone 2W1� <br /> Owner's Name _5...� Address <br /> Conlfactor�� L!K D�[LIN6 x- Address 3 3I<Z6N& #V License NO_330fa f�done_ - ZS �t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring well <br /> � r V <br /> DISTANCE TO NEAREST: SEPTIC YANK 7�0•� SEWER LINES 7-'57.0'-- DISPOSAL FLD,�_ PROP. LINE R� <br /> FOUNDATION 7SQ AGRICULTURE WELL 75o OTHER WELL <0 PITS/SUMPS Q. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •i j <br /> n industrial (3 Open Bottom ❑ Manteca Die. of Well Excavation_ IQ -- Dia. of Well Casing <br /> G Domestic/Private Gravel Pack Tracy Type of Casing P�C- Specification$ 9c>rde <br /> 0 Public (1 Other ❑ Delta Depth of Grout Seal ,544 l:c•ce - '3 Type of Grout � <br /> I! <br /> 0 Irtigation �--Approx. Depths D Eastern Surface Seal Insulted by <br /> Repair Work Done U Type of Pump SPL._ SudH. Stats Work Done <br /> Well Destruction O Well Diameter 14 " Sealing Material 4 Depth Rf <br /> Depth Jnr �yy ` --- Tiller (Material i Depth " it L C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DER'A 1� ruseptic system permitted if public sewer is <br /> 1'f'1 1- ble within 200 feet.) <br /> Installation will serve: Residence— Commercial_ OtherRECEIVED <br /> Number of living units: - Number of bedrooms <br /> Character of $oil to a depth of 3 feet: MAY M AY Water table depth r <br /> i IIN C01 NT*. Compartment <br /> SEPTIC TANK. D Type/Mfg Ca�11YInA,.�Q <br /> PKG. TREATMENT PLT,CT PUBLIC HEALTH SERV Q4fhod of Disposal <br /> Distance to nearest: Wali FouN�la PPMENTAL HEAbT VIaq I' <br /> �I <br /> n <br /> LEACHING LINE CI No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ d <br /> I hereby eenify 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> empioy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> conifies the following:"I eenify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applies =U01equired,inspaCtionS. Complete drawing on reverse side, F <br /> 11 <br /> Title Vit_ . ���-E!b C�Q3 S - i Z <br /> Signed Z ~ <br /> Date: y. <br /> FOR DEPARTMENT USE ONLY <br /> ') <br /> r`v <br /> Application Accepted by Date Area (' <br /> Pit or Grout Inspection by Date �y Final Inapattion by r° f Date /Z <br /> Additional Comments- <br /> Applicant - Return all copies to*-W BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PFJtMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 20DR, STOCXTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECErV D BY DATE PERMIT'-4 <br /> 9a t._ZYtlIEV.riRel g ( �� 9/ ' �� IS�`7 /f.' � f/Yo� q-2 —2&3 <br />