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APPLICATION FOR PERMIT lwl� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468— 3420 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is nada in coMllance with Sats Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations or San <br /> Joaquin County Public Health Services. <br /> � ) l_ J ASN /25—/40-1-7Job Address 2-31,SIVO 1�l�.yfY(i+3ti �7� City z, Lot Size/Acreage '60 Ac. <br /> Owner's Name�+eOrIPN (J�/�P[/irJ li E Address 6_232 llew't !ye,2 i:% 4 VI.z Phone 4'11- 7 <br /> Contractor Address 01&)•x 2.Z3' License No. 672("I Pho4 ` <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Nell O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK . 4)�_ SEWER LINES 2, ' DISPOSAL FLO.G�'I PROP. LINE /n , <br /> FOUNDATION �� r AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Z <br /> (2�Domestic/Private 19 Gravel Pack O Tracy Type of Casing- P4 Specifications SC/i1 4y <br /> O Public ('1 Other O Delta Depth of Grout Seal -57t),' l-0- Type of Grout. <br /> G Irnuation IL.Approx. Depth O Eastern Surface Seal Installed by CCa•I YGC"(-i - <br /> Repair Work Done U Typo of Pump M.P. . State Work Done <br /> will Destruction O - Well Diameter Sealing Material i Depth <br /> Depth Filler Material ti Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AbDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 lest.) <br /> Installation will servo: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity—__, No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. b Length of lines _ Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS O <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordanca with Sari Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner of licensed agent's signature certifies the following: "I cosily that in the performance of the work tot which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting 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 componsa• <br /> tion laws of California," <br /> The applicanl us c 11 r II requ' ed insps•Ctions. Complete drawing on reverse side. ,J9 <br /> Signed Title: .6_4,t:;QLrAA_1_T_ /GAG <br /> Dote: <br /> FOR DEPARTMENT USE ONLY (/ <br /> Application Ac pled by Date J Area <br /> Pit or Grout Inspection by Date ( (�� Final Inspection by Date <br /> Additlonal Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IIEALTH DIVISION PERMIT/SERVICES a f <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 (f/ <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK- <br /> SH RECEIVED By DATE PERMIT'NO. <br /> ` <br /> INFO <br /> iH IJ•71 It1EV.Ire lr Oho [I� <br />