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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> s ENVIRONLIENTAL HEALTH DIVISION RECEIVED <br /> � � � <br /> '445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 N ION 2 3 1992 <br /> SAN JOAQUIN COUNTY <br /> PER?IIT EXPIRES 1 YEAR FRQ1M DATE ISSUED P;JgL;C HEALTH SERVICES <br /> (Complete in Triplicate) ESVVIRONMENTALHEAI_THDiVic. r, <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in a:ade in caayliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 2,P-63 /n� __ fI D <br /> E-C+fLt11i _ City Lot Size/Acreage <br /> Owner's Nome �S�Df� C Address J 1 C-+ i]y C L��Phone <br /> C <br /> Contracts Address i License No. 9R�Sya Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Hell ❑ <br /> PUMP INSTALLATION ❑ ;SYSTEWREPAIR OTHER O lSonitoring Well O <br /> 1DISTANCE TO NEAREST:`SEPTIC_TANK SEWER LINES DISPOSAL FLD. PROP. LINE t- <br /> FOUWDAfION "'�""�"`" AGRICULT.URE`WELL'-1"L"`�OTHER WELL'h'� P17S/SUMPS; <br /> END <br /> INTED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N <br /> 0 Industrial 0 Opon Bottom, ,r❑ � <br /> MantecaDis. of Well Excavation Dia. of Wep Cacing <br /> �Domectic/Privato O Gravel Pack/ O <br /> '1 PTracy f.s,� Type of Casing_ Specifications <br /> ublicCl,,�1 Other ' <br /> IF1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigalioit•:r.: �L� :Approxt'Depth i I I Eastern Surface Soul Installed by <br /> Repair Work D666 U Tyl of'Plump H.P. ' Statq Work Done�. <br /> Well Dcatfuction -a/WeN Diameter Sealing tzterial'6 Depth <br /> Depth 16b• Filler lrsterial 6 Depth <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 tNo septic system permitted if public sewer is <br /> available within 200 foot.) <br /> Inateffation w4l carvo: Rocidenco_ Commoreial— Other <br /> Number of living units: Number of bedrooms <br /> Chorecter of coil to o&pth of 3 foot:,; Water tabl3 d3pih <br /> SEPTIC TANK. O Typo/Mfg" Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> 1 Dialance to nearest: Well Foundation Property Lino <br /> LEACHING UNE O No. G Length of linos Total length/size <br /> FILTER BED O Distance to noareat: Weft Foundation Property Lino <br /> SEEPAGE PITS 11 Depth Size Number r <br /> ;,_SUMPS. LI�Diatenco_to r=rcat:- Wofl_ >_._ __-FbunAation Proporty.Lino, - - <br /> DISPOSAL PONDS O 1 f <br /> I hereby sonify that I have prepared thi3iapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ruba-and rcqufations of the Son Joaquin County I <br /> Homy owner or licen_tod o9ant'o d9natui0 eortifios the following: "I certify that in the performance of the work for which this'pormit is issued, I shall not <br /> employ any per 'ouch mennor as topecome oubjact to workman's compensation Iowa of Colifornia." Contractor's hiring or sub-contrecting signature <br /> cortifga the f i :;I conity that in tho portormcnco of the work for which this permit is itouod,I shall employ portions subject to workmen's compenea- <br /> tionl3wa Cal Ln-" r` i <br /> �,Tia appf6ca` t call for 0 r' od iris Complete drawing on reverse side. <br /> Signori - Title: X% Date: <br /> �• FOR DEPAOTMENU USE ONLY <br /> t Z <br /> Applicction Accepted by Date 'Area <br /> Pit or Grout In_poction by Date ' Final Inapection by ` Onto <br /> Additional Commants: f. <br /> Applicant - Return all copies to: San Joaquin County "Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO A UNT DUE ) AMOUNT REMITTED K ECEI 0 BY ATE PERMI7'NO. <br /> . EM tits inEv.riesr Ct_ i� ", ,/ o <br /> LN 71.98 VVV��� /x y' <br />