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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 0 BOX 2009 , STOCKTON, CA 95201 <br /> PERMIT R R <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin Couaty for a perm-It to COnatruct and/or install the work herein described. This <br /> application is made in eampliwce with San Joe.quin county ordinance No. 549 and 1862 &M the Rules and Regulations of San <br /> Joaquin County Public Eealth 19ervices. <br /> Sob Addreu 3 SO T1f EdTr S�� Y City1`-0CKTO� Lot Size/Acreage'v( <br /> Owner's Narne C VR U' S' A ' Address 7,Q' 30A 500 41.5 /tel\�nf--C�' p!►One 510 Z 5540 <br /> Contractor C�/iEGI�? Y 1LC1�/Gt Address N �iCtn�r iVk. 7 phone��� S <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 5 DESTRUCTION ❑ Out of Service hell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ TLonitorirlg Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N <br /> 0 Industrial ❑ Open Bottom D Manteca Pia. of Well Excavation J5 Dia. of Weli Casing 2– <br /> r.1 <br /> fl Domestic/Private KGrave; Pack O Tracy Type of Cssing.S� DVC--- Specifications <br /> f'I Public n Other ❑ Delta Depth of Grout Seal O'Te5 3/' Type of Grout Ce E�✓7 <br /> 1 I Irrrpaiion 6o' Approx. Depth/ I i Eastern Surf ce Saul Installed by LL <br /> 1,0161 <br /> Repair Work Done U Type of Pump - 'tj1A ---- H.P, an __ Stats Work Done _A) <br /> IA <br /> Well Destruction (] Well Diamelet Z-'ING�I Sealing liaterial i Depth l40a �' <br /> Depth 6o Fr ricer Naterial i Depth �� e4,4: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRlADDITION I I DESTRUCTION I I (No septic system permitted it pitb4c sewer is <br /> available within 200 feet.) <br /> Installation wilt serve: Residence — Commercial — Other <br /> Number of living units; Number of bedrooms <br /> Chwxatw of nom to a dwprh of 3 toot. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capachy No, Contpannwnts <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. A Length of lines Total length/size <br /> FILTER BED ❑ Distance to rwarast: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundat>on Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will tib done in accoioance with San Joaquin county ordinances, slate laws, and <br /> rules and rpulatroro of the San Joapuin County <br /> Horns owner or licanaad agent's li+gnaiure oartifws the following "I Certify thai in the performance of the work for which this permit is issued. I shall nor <br /> OmPi0y any Pwaon in such manner as to become sub}ect to workman's compensation taws of California," Contractor's hwtno or sub-Contracting s+gnature <br /> C',ndpas the tobowirv: "l urtity that in the performance of the work for which this pernvi is issued. I small employ persons subject to workman's eompen&s- <br /> non Laws of Calitornla." <br /> Tho applicant nkjst Call lot 0 squired inspaCtrons. ComDlaie Crowing on reverse side. <br /> Si¢Md / �^ CGrT Title: rlSst?c/rf G�[041-SJ-- Date: �1�10 ' 9S <br /> �]A OR ARTMENT USE ONLY <br /> Application ACCebtad by � i V� Date JJ G ('J1 r Area `! <br /> Pr1 or Grow[ Inafle.ttion by Date <br /> Final Inspection by Onto <br /> AddliorW Comrnenu: <br /> AppllCant - Return all coplee to: San Joaquie County Public Ifealtt: Services <br /> Lnviroomental healtb Permit/Services <br /> 445 i; Sao Joaqulr+, P O Box 200p, Stkn, CA 95201 <br /> I <br /> INFO <br /> A►s DUE OUNT�ifsAinED C,Sf t RECEIVED pY DAT[ PEAMt1 NO <br /> Ir o�v <br /> EK 1136 Iri[V. i i•u <br /> f K u.as 6 -7 <br />