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Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 1 <br /> It PERMIT EBPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made-'u San Joaquin County for a Permit to construct and/or install the vork herein described. This <br /> application is rade in compliance vlth Ban Jcaquln County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> -1 <br /> Job Address ��6 , I <br /> ✓Lot <br /> rLie�Sl-^{ze"/A�c,-reoengee <br /> Owner's Namer kY, Address <br /> Conttacto t / License Nt� —P <br /> hon-�sl ` r+ A �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well G <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL�i® / PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -i 0 <br /> G Industrial Ci Open Bottom G Manteca Dig, of Well EAcavauon � Dia. of Well Casing 612 <br /> %4omestic/Private tr�lcaravel Pack G Tracy Type o1 Casing_ Specifications'''7)'— _ <br /> I'I Public 1:1 OI <br /> G Delta Depth of Grout Seal ..I�r l��o T of Grout <br /> M r <br /> Irrigation 6f Depth I I Eastern Surface Seal Installed by/ e"A III HP' <br /> Repair Work Done LJ Type of Pump H.P. State Work Done _ <br /> Wad Destruction ❑ Well Diameter Sealing Matti III, Depth <br /> Depth Filler Material a Depth <br /> TYPE,OF $$O�PTIC OliI�: NEW iNSTA1y.gTION I I REPAIR/ADDITION I I DESTRUCTION I I (No septresystem permitted it public sewer is <br /> /yt,N qY U NQ'sk"1 olJ� \/✓'tAj available within 200 first.) <br /> InstWation will verve: Residence_ Commercial_ Other <br /> Number of dving units: Number of bedrooms <br /> Character of sod to a depth of 3 fast: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. LI - Method of Disposal <br /> Distance to nearest: Well Foundation Property Lire <br /> LEACHING LINE G No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearesC Well Foundalion Property Line <br /> DISPOSAL PONDS C <br /> 1 hereby conity, that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulationa 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 Iseued, I shad not <br /> employ any person in such nannar as to become subject to workman's compensation laws of California."Contractor's hiring or sob-contracting stgri <br /> confess the fodovnng: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- <br /> tion laws of Califurni <br /> The applicant <br /> /1-y�lat call for all required <br /> inspections. Complete drawing on (over" side. <br /> Signed X L! !4- {4,�.& Title: kLl 1K,O Date: <br /> OR DEPARTMENT USE ONLY i <br /> Application Accepted by 4L#& tA _ - Daie %Z L 1� Area f72 7- 1 •� <br /> Ph o Ispection by Date� Final Inspection by Date <br /> Additional tx <br /> Cnnente' /9 49;%/A%�`YfA.>✓.D//�/�7�%.�.RsrO�/-iS�F�a-'/•Z�:Cl/� % �+�Y�/96%�S/ <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 <br /> NFEE <br /> PO AMOUNT DOE AMOUNT REMITTED I (ASH RECEIVED BY DATE PERMR'NO, <br /> O <br /> . FH tat.1AEV.,,�s,W4 � , 00 , , ca3 W//4a <br /> FR ta.a <br />