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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S <br /> ` ENVIRONLIENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> -_, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby rode to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is =ado in compliance with Ban Joaquin. County Ordinance No. 549 and 862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 791 <br /> -Job Addreaa f l R��� City Lot Size/Acreage <br /> Ownor'a Name Address PhoneN2.—. <br /> V <br /> Contractor dress J License No. PhoneEK <br /> / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REP IR O OTHER O 14onitoring Well O <br /> D19TA-NC TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. � PROP. LINE <br /> FOUNDATION A (CULTURE WELL OTHER WELL " PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTR TION SPECIFICATIONS ' <br /> ❑ Industrial� ❑ Open Bottom ❑ Manteca X10lia. ofoli Excavation r Dia. of Well Caning <br /> l'1 Domoatic/Privato O Gravel Pack ❑ Tracy asingSpecification1"1 Public fl Other n Delta Gi'o'Ur&ial "-�"� ' Typo of Grout <br /> I I Irrigation _..-Approx. Depth l I Eastern i eal Installed by <br /> Repair Work Dorso L� Typo of Pump H.P. I State Work Done'_ <br /> Wea Dootruetion O a Well Diamotor Scali l!3terial E Depth' r <br /> Dopth. `'' Filler Xateriecl•hi Depth � . i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I W REPAIR/ADDITION i I DESTRUCTION I I (Nosepticsystem permitted if public sower is. <br /> � <br /> � available within 200 feet.) <br /> ill i <br /> Installation wczrve: Roaidonco L"'� Commercial <br /> Number of living units: Number of bedroom, <br /> Chcrtxta of toll to o depth of 3 foot: _ Water table dzpth C <br /> SEPTIC TANK. . 0 Typo/Mfg Ccpacit, No. Compartments <br /> PKG. TREATMENT PLT.O <br /> >' <br /> _ ;Method of Disposal ot <br /> Diatance.to nearest: Well �Q ' foundation Property Lino• C <br /> LEACHING LINE C1 No. &Length of linos T al length/size 2 of <br /> FILTER BED O Distance to nearest: Well 00 0 Foundation f- Property Line <br /> SEEPAGE PITS I 1 Depth Size t Number <br /> SUMPS LI Diatanco to nasrost: Wall Foundation P1010"Y Lino (� <br /> DISPOSAL PONDS O <br /> I 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 rogulaliono of the Son Joaquin County <br /> Norm owner or keneod 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 peroon in ouch mcnner as to bacerns subject to workman's Eomponsation laws of California."Contractor's hiring or sub-contracting signature <br /> conifizo tho fo0owing: "I certify that in the porformenco of the work for which this permit is issued,I shall employ persona subject to workman's componsa- <br /> tion Iowa of Cclifornio." <br /> The applican at C04 required in poetions. Complete drawing on reverse side. <br /> Signed Title: _ rim Date: <br /> R DEPARTAAENT USE ONLY <br /> Application Accepted by Dato <br /> \ � � <br /> /��,,.���'.'.C�,� Area� ��n, S <br /> Pit or Grout Inspection by Date Final Inspection by�=0 Date�-cZd <br /> Addhioncl Commonta: da .4- "Va6w (Av i <br /> Applicant - Return all copies o: San Joaquin County Public Health Services <br /> Environmental Health Permit/Servicee <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED K CEIVED BY pAT£ /PERMIT NO. /� <br /> . EH 13-24INEV.iim51 -c-M 1 a!U is'l1 �� 11/' /Y i /Ji e��� k;W <br />