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h <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES `� r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 1D(Ji <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �- t� � <br /> /Job Address �� CityrLot Size/Acreage <br /> ✓Ownei s Namef' L�---�i/JLG /JWj -Add/e � .Cy GLV phone <br /> i/ Contractor (1 do:1=&-) Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ tl'' YSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N <br /> III i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS <br /> C! Industrial ❑ Open Bottom ❑ Manteca ! Dia. of Well Excavation Dia. of Well Casing <br /> Cl DomesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications " <br /> I'I Public C7 Other n Delta Depth of Grout Seal Type of Grout �1 <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P i State Work Done <br /> Wali Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth '. f Filler Material i Depth <br /> OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitre ublic sewer is { <br /> bailable within 200 <br /> Installation will se nce— Commercial Other <br /> Number of living units: of bedrooms----� <br /> Character of salt to a depth.of 3 feet: ;t Water table depth <br /> SEPTIC <br /> TANK ❑ Type/Mtg tt `` C!RaoNo. Compartments f <br /> PKG. TREATMENT PLT.0 l Method of Disposal <br /> Distance to nearest: WelIF Founds Property Line <br /> A <br /> n <br /> LEACHING LINE ❑ No."If L��2&r�est <br /> ` '""`Tot`al leng e FILTER BED ❑ DistaWell Foundation t Property Lin t <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Distance to ns8rist: !Well ' Foundation Property Lina ? <br /> DISA0591. PONDS . ❑ <br /> 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 r <br /> rules and regulations of the San Joaquin County 1 I <br /> Homs 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 i! <br /> employ,any person in such manner is to become subjegt to work man's-compensation,lows-of.CaNf.ornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Colifornla." <br /> The applicatrot 0811 for al r 1 spa ns. Complete drawing on reverse side. <br /> V/Signed Title: ti/rlaca� t - �� Date: <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by _ __ r �fl Ma Date d- J ZLArea <br /> Pit or Grout Inspection by Date Final Inspection h, lvx Date <br /> Additional Comments: <br /> Applicant - Return all-copies to; San Joaquin County Public Health -Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> V FEE <br /> INFO JV AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> INF <br /> . Ek17.2 [REV.1iR5) <br /> EH 11-96 �N <br />