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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)458-3420 <br /> P O SOK 2009, STOCKTON , CA 95201 <br /> [ <br /> PERMIT EXPIRES 1 YEAR FROM DATE UED <br /> (Complete ,in Triplicate) <br /> r � • > <br /> Application is hereby made to San Joaquin County far a permit to construct and/or install the wo:'r. hereln described. This <br /> application In made in compliance with San Joaquin County Ordinance No_ 549 and 1862 and the Rules and Regulations or San <br /> Joaquin County Public Health S rvic^ea►. <br /> Job Addre64cZ/0`/� iry ,!fpQ Lot Ssze/Acreage <br /> 1 <br /> Qwne["s Name ��`•"" �" � �� Address-Z3954!n ! <br /> 0 64Aj�>f� Chi/Ysyr one 15- 3-5680 <br /> rC4gS z <br /> Conlydtlor �F_ W_ _ Address'[" �/l7fC1! I, euKrr+w`■ Liiense No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i-1 DESTRUCTION i� Dut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 6ze- eRA*444—Monitorling Well f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation D'a- of Well Casing <br /> f.I DomesticlPrivate ❑ Gravel Pack L7 Tracy Type of Casing_ /r✓d� _ Spec ftcations <br /> V] Public II Other VI Delta Depth of Grout Seal - 5� /bJry Type of Grout <br /> — <br /> i I IrnUation Approx. Depth I I Eastern Surface Seal Installed by $AGS VATJVf-� �&T <br /> Repair Work Done i] Type of Pump H - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Materlal & Depth ti <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permuted if pubrtc sewer is <br /> available within 200 feet.[ <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms ` <br /> Charactef of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK 0 Type/Mfg Capacity No, Compartments Q I <br /> PKG. TREATMENT PLT. ❑ Metff i@[� <br /> Distance to nearest: Well Foundation Properly Li � <br /> LEACHING LINE Ll No. & Length of lines Total length/size Li-15•_r?Y rt F <br /> FILTER SED 1-1 Distance to nearest: Well Foundation Props"im"' tJNT,t, <br /> ellEU Ir' I- FAI T+.t <br /> SEEPAGE PITS 11 Depth Site_ �_ NumbaENVMQNMF�1F i HFlslJTH ili'y.iv;l;ti' <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 <br /> Home owner or licensed agent's sigriature cenifies the following: -I certify that in the performance of the work for which this permit is issued, I shalt 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 compensa I <br /> tion laws of California." r <br /> The applican u 11 f all required inspections. Complete drawing on reverse side. ��ZWYtj&4W,.ata: <br /> Signed X Title: ��FA7,ce'617 Z <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Oate Area <br /> Pit or Grout Inspection by Date Final Inspection Data vl' <br /> Additional Comments; <br /> Applicant - Return all copies to, San Joaquin County Public Health <br /> Servicee, Eavironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IFEEO AMOUNT DUE �AMOUNT REMITTED CK a RECEIVED BY DATE PERMIT'Np. <br /> . fM1J•24IM.rrnsls CJ-LI Y 09 Z-7 <br />