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APPLICATION FOR PERMIT �- 1� <br /> SAN AO IN COUNTY PUBLIC HEALTH SE CES RT��JaIdZ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> APR 13 1993 <br /> PERMIT EXPIRES 1 YE 'f'FR M DATE -ISSUED <br /> O <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to San Joaquin County for a .permit to cc'natruct and/or install the work ���MT1�ic}tU This <br /> application is made in'pceiliance vith Ban Joaquin County Ordine,nce.No. 549 and 1862 sad the Rules and Regulations of San <br /> Joaquin County Public'Sealth services. <br /> Job Address / ft /OQSO Sflu'g 67 4rado s4 :'City `r `�� I.ot Size/Acreage <br /> /-Loo S. m s¢, rc,A- -7/081' <br /> Owner's Name w Addreu �!I �� ---- - Phone <br /> GS7 '� <br /> f 3 • <br /> Contractor QLfff/I Address 334 �C d I/IS icense No.5 / . ' 1'nane �0 37 I��D <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION 5 Out of Service bell 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER O Monitoring Vell <br /> DISTANCE TO NEAREST: SEPTIC TANK - e�10 SEWER LINES �� DISPOSAL FLO. N PROP. LINE <br /> FOUNDATION 'CZS +-AGRICULTURE WELL; N h' OTHER WELL 57S PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation i&lchar Dia. of Well Casing e <br /> [;l Oomesticl Private 0 Gravel Pack 0 Tracy Type of GasingS[`I. YO VC Specifications - <br /> I'I Public $<other i"1 Delta Depth of Grout Seal Type of Grout <br /> �6t/r <br /> I i Irrigation Apprott. Depth. 1 I.Eastern Surface Seal Installed by G�so & <br /> Repair Work Done 0 Type-of Pump H.P. a State Work'Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material4 Depth <br /> pepth filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wig serve: Residence— Commercial_ Other <br /> Number of living units:: Number of bedrooms <br /> Character of sod to a tfeptlt of 3 feet; -Water tabu depth <br /> SEPTIC TANK 0' Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ' Y <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line # <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Founditiori Property Linc <br /> DISPOSAL PONDS 10 I� <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 reputations of th4i San Joaquin County <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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub conlractinq signature <br /> candles the following:"I cattily that in the performance of the work for which this!parmit is iuued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." r (� <br /> The applicant must N f ON required inspections. Complete drawing on reverse 1�l <br /> Signed X Title: ct a r 4 r 11 Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ✓" �­P Area <br /> Pit or Grout Inspection by.: Dater j <br /> Final Inspection by Detas� � <br /> Additbnal Comments: 79F1� <br /> Applicant - Returp all copies to:- San Joaquin County Public Health Services <br /> Environmental Health Permit/Services f <br /> a 445 N Sam Joaquin,-P O Box 2009, Stkn. CA 95201FEE <br /> d�/J <br /> INFO AMOUNT DUE AMOUNT REMITTED' CA# RECEIVED DY DATE /PERMIT'NO. <br /> . <br /> IN 1}2t IrIEV.t/sS! Z�Z/a4 L 3.. ./d 876 <br /> tS" <br /> 14-30 <br />