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APPLICATION FOR PERMIT <br /> QUI <br /> SAN aJNMII4TALPUBLIC <br /> HEAI,TH DIVISION�V�m <br /> ENVIRD <br /> 445 N SAN JOAQUIN, PHONE (209)468 <br /> P O BOX 2009, STOCKTON, CA 952QC <br /> PERMIT EXPIRES 1 YEAR, FROM DATE ISSUED, <br /> (Complete in Triplicate) <br /> . _ 1��^UIi�I�irim�lYNilrr <br /> Application is 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 .9E 4 N W O City s C>> iV Lot Size/Acreage <br /> Owner's Name Address U "�&x ..C/07 c_d4F�Gly-- Phone "'�¢ <br /> i <br /> I Contractor CAL1AZW L99L40ddress 3jQQS • se Nd'.40120_' Phone LIZ' 7 <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Out of Serviee�well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring,well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _/1 <br /> n <br /> Industrial ❑`0 n Bottom ❑ Mantea Dia. of Well Excavation Dia. of Well Casing; <br /> �V <br /> Cl Romesti /Privats ❑ Gravec Pack ❑ Tracy Type o1 Casing_ <br /> Specifications <br /> , <br /> IT-Nitwic fa_Other' "' n Delta Depth of Grout Seal Type.of,Grout, <br /> I 1 Irrigation ___:,,Appron; Depth ...;I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ f Type of,Pump H.P. State Work Done <br /> Wall Destruction (mss Well"Diameter j� [[f� Sealing.Material A Depth <br /> Depth l�r�'J'" Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I 1 DESTRUCTION I 1 lNo septic sysiam permilted it public:sway is <br /> available,within 200 faet.l <br /> Installation will serve: Residence Commercial Other <br /> Nurrtbit of living units. Number of bedrooms <br /> Character Of"to a depth of 3 feet: - Water tal�. � <br /> Sep,TfG�TANK,. O Type/Mfg Capacity No. to, <br /> PKG. TREAT!0ENT'PLT.CQ �, ' '.;$" t Method <br /> ... Distance to nearest: ..,Well Foundation Property Line �. <br /> r LEACHING LINE Ll No. 8 Length of lines " iTotil length/size Si�N;DAQU# <br /> FILTER. BED . Gi Distance to nearest: Well Foundation � Prope�jt� ��L��p�u�sJ�Q� <br /> ;.a tNN <br /> SEEPAGE PITS I 1 Depth size ' <br /> SUMPS _ Ll Distance-to nearest:. Well Foundation y Property Line4. <br /> DISPOSAL PONDS ❑ ; <br /> I haraby certify that l have prepared this application and that tt4 work will be done in'accondance with San Joaquin county ordinances, stats laws, and <br /> i rules and regulations of the.San Joaquin County i 1 <br /> Howie owner or licensed agent's:`nature certifies the followin : "I certify that in the perfor ance of the work for which this permit is issued,1"I not. <br /> ,employ any person in such manner as to becoms*006 7awo4i�men'a compensation laws of.California.".Contractor's hiring or.sub-contracting.signature <br /> eartifies the following: "I"ki}y that in the performance of the work for which this permit is issued,I shall employ parsons subject to woAmin'i t ompensa- <br /> tion laws of Califomia." i <br /> The applican It 1 gr alMrs <br /> inspections. Complete drawingon erse si e: <br /> Signed Title: Date: ! <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �. _ Date i <br /> Pit or Grout Inpaclion by Data Final inspection by Daces i`t <br /> Additional Comments: / <br /> Applicant - Return all copies to: San Joaquin County P b is Hes h Sery es n I <br /> Environmental Health Permit%Services Cold "-" <br /> 445 N San Joaquin, -P O Box 2009; Stkn, CA 95201 <br /> (J i <br /> Ccs/ <br /> IFEE NFO AMOUNT DUE AMOVN7'REMITTEO CK R RECEIVED BY GATE PERMIT NO. L � <br /> . 69 <br /> EH 13.2i111EV.1/ 51 Dim <br /> EH 14-M V�/_J <br />