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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> _ P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 15 hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This <br /> application is 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 /> ` Job Address IC2 P, S, /yA2 LAn/ .2 D City jc-,C_ Lot Size/Acreage 4 e- S <br /> Owner's Name -S'7_"-4`/0-7-SNUPS6e—. ' yAddress _ P06&X 3'P/ Phone '7 . -O S <br /> Contractor FLOYp b'. Lr/oetp Address _7 Al, A`Af166feQ:— A -ff License No. hdyi J'7� Phone 397/ <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT 7.1 DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER D Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ya INTENDED USE TYPE OF WELL PROBLEM REA CONSTRUCTION SPECIFICATIONS <br /> rl Industrial D Open Bottom D Manteca D' of Well Excavation Dia. of Well Casing <br /> O Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public 0 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 Imgation —Approx. Depth 0 Ea n Surface Sedl installed by <br /> Repair Work Dona 0 Type of Pump H.P. State Work Dona _ ^\ <br /> Well Destruction D Well Diameter - Sealing Asiterial i Depth <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Cl DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will grvs: Residence _ Commercial c/ Other <br /> Number of living unite = Number of bedrooms —' <br /> Character of soil to a depth of 3 feet: 'D C< Water table depth <br /> SEPTIC TANK EI Type/Mfg Gam- -Pq-L Capacity 1cJyn <br /> p y No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> n <br /> Distance to nearest: ell irk v Foundation y.S Property line <br /> � LEACHING LINE No. g Length of lines 10 - /00' Total length/size 3oC7' <br /> FILTER BED 0 Distance to nearest: Well ;2-( ti -rL Foundation 3tA Property Line //)O S' <br /> SEEPAGE PITS 11 Depth Sire - Number a <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 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 regulations of the San Joaquin County <br /> Home 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-contracting signature <br /> csniliss the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persona subject to workman's compensa. <br /> tion laws of California." <br /> The applicant must call!fpr all required inspections. C mplete drawing on reverse side. <br /> Signed X Title: �i`x�Lri <br /> Data: /d-/9-40 <br /> t`�''l r, Q <br /> Application Accepted by y2Ot FOR DEPARTMENT USE ONLY <br /> ham_ Da[el� �,-`� `J Area ca)25 <br /> Pit or Grout lnspectio Date Final Inspection by 441" 11,:7Dais ` C <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> !NFO AMOUNT DUE AMOLINT REMITTED `CASH RECEIVED aY /- DATE rPERMI/T�-NO. <br /> SFR 1LM IaEV.i,na; `111 L'V �� U`` 1�� IF _��� 11C;����—G/(7 CL i^J ('J��IJf <br />