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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 )M FROM DATE S <br /> 4 (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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> n <br /> Joaquin County Public Health Services. p . <br /> City n s J___ art%-- Lot Size/Acreage <br /> Job Address <br /> i <br /> Owner's Name <br /> '4'oI" YCC✓GAddress «��� f�re�"rch C1W-1e )W- Phone <br /> Contractor ��' <br /> �jp/t/ 5vN Address 00A Lvg V!7 /�1> � License No. �� _Phone <br /> TYPE Of WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ Out t4 Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT$ISUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 7 of Casing- Specificons <br /> [1 Domestic/Private ❑ Gravel Pack E7 Tracy Type Casg- ati <br /> Type a1 Grout <br /> I'1 Public Cl Other fl Delta Depth of Grout Seal <br /> I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by F <br /> Repair Work Done ' L3 Type of Pump H.P. State Work Dane, <br /> Sealing Nateria.l i Depth <br /> Wall Destruction ❑ Well Diameter Miler Material i Depth <br /> Aw- : .Depth--- -� 1 <br /> 1 Ilio septic system permitted if public rawer is <br /> TYPE OF SEPTIC ORK: N NEW INSTALLATION I I REPAIR/ADDITIODESTRUCTION l <br /> W ` <br /> available within 200 feet.) <br /> Installation will serve: Residence 'l.--Commercial^ Other <br /> III Number of living unitti' S Number of bedrooms s j <br /> Water table depth <br /> Character of soil to a depth of 3 fee <br /> t: a <br /> SEPTIC TANK. ❑ Typs/Mfg Capacity No. Compartments ' <br /> Method--of-Disposal,: -- ' <br /> PKG. TREATMENT PLT. Q <br /> ►; Distance to nearest:-,* Well Foundation Property Line <br /> LEACHING LINE 0 No. b Length of lines �� f ;t?/ Tonal length/size <br /> iFILTER BED 0 Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS I I Depth l Sire Number <br /> SUMPS Lf Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordin&A6es, state laws, snd ` <br /> l rules and regulalk"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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all for all required inspection&. Complete drawing on reverse side.` <br /> tYrs/ Title: Date: J I- ` "g Z. <br /> Signed <br /> R DEP Mi <br /> Application Accepted by <br /> Dais ArS.&S <br /> Ph or Grout Inspection by <br /> Date Final Inspection ' Batu <br /> Additional Comments: <br /> a Applicant - Return all copies to: San Joaquin County Public Health Services <br /> .�Environmental,Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2000, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY TE PERMIT'NO. <br /> INfF1O i 901 <br /> _... EH 13d4111ty,Vr14s1 Z21C <br /> EM 110•20 <br />