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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) 468-3447 <br /> PERMIT EXPIRES 1—YEAR ?RQM SATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mnde.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 Sen <br /> Joaquin County Public Health Services. <br /> S 7W CA-az.J �S <br /> Job Address _,Ay�,9­5' ;�A.C�GtI/LDS - City Lot Size/Acreage <br /> I <br /> Owner's Name :IM SC Va4—L- _ Address sftrrlE Phone <br /> Z <br /> ContractorT > 4�'LQ ' Gc��D_-^-Address� 7 n1.-Asp G,B. _.4-r/E_.Lice.nSe.No. P_hone 6S 3471 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_� Industrial 1 ❑ Open Bottom 0 Manteca Dia. of.Well Excavation Dia. of Well Casing <br /> U Domestic/Private ® Gravel Pack ❑ Tracy Type-of Casing Specifications (7- <br /> M <br /> M Public (7 Other Q Delta Depth of Grout Seal Type of Grout <br /> -- <br /> CJ Irrigation ,_..Approx, Depth 0 Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Dane <br /> Well Destruction © Well Diameter sealing Material 6 Depth <br /> Depth Filler Material i Depth +4 Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION.0 DESTRUCTION )<i INo septic system permitted if public sower is <br /> / iv available within 200 feet.) <br /> Installation will serve: Residence v Commercial_ Other V Gp,ya,o7pe//y31 111A7"e,-f- <br /> Number of living units: --L Number of bedrooms <br /> Character of soil to a depth of 3 feet: ye Water table depth J <br /> SEPTIC TANK Type/Mfg p9f`�- Capacity .12-00_ _ _ No. Compartments 4 a <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well tJLA Foundation. Property Line `3d <br /> LEACHING LINE No. & Length of lines — 1-70 t <br /> g _ Total length/site <br /> FILTER BED n Distance to nearest: Well_/g_ Foundation Property Line r <br /> SEEPAGE PITS IW'Depth LSr _ Size �� "� ,T Number 5 <br /> SUMPS LI Distance to nearest: Weil �.g Foundation �_ Property Line s� <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 signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmen'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 workmen's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections:-Complete drawing on reverse side: <br /> r <br /> Signed X 4==rle Title: __ Date: G'1 D- q I <br /> t ; <br /> FD�. _s ONLY <br /> Application Accepted by Data 1 1 Area <br /> Pit or Grout Inspection by l Date Final Inspection by sS Date 6 i- <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVAgIONMENTAL SAN HEALTH DIVISION <br /> JOAQUIN, P 0 BOX2009,PERMIT/SERVICES <br /> TOCKTON <br /> 5CA 85201FEE <br /> / <br /> INFOT T�AMt�NT3E 'TiMOVrJT REMITTED '- CASH RECEIVED"8Y DATE PERMIT'N0. <br /> I <br />