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_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SuJICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)458-3420 <br /> P O 80% 2049, STOCKTON. CA 95201 <br /> PERMIT__EXPIRFS_1YEAR PRO <br /> (Complete In Triplicate) <br /> Application is hereby made to San Joaquin County fpr a permit tv rcnatruct and/or install the work herein described This <br /> application to made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rues and Regulatione of San <br /> Joaquin CountyPublicHealth Services. <br /> Job Address _ X71 S` iM____f AL Z:1_Ta _ ly?fl A City .LLot bine/A-reagie <br /> Owners Name 216Iit�l�L� ��_L'c"�� u_trA, �,ddrerss 7 7 LiYP(�✓ -S f} L TT Phone <br /> THS ur'c of 11 f ^' Q• ¢ J7 a b�r r c A <br /> Contractor �; f + Address 3r3 �� vuJ�Z�,-y1 L cense No ,f,l�i �Yhonc <br /> TtPE OF WELL/PUMP NEW WELL. 0 � WELL REPLACEMENT 7 DESTRUCTION DKout of Service well Ll <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ^u OTHER 0 Monitoring well C, <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE T1 PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial 0 Open Bottom O Manteca Ora of Well Excavation _ Dia of Well Casing <br /> (I Domostic/Ptdvate ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> I Public I 1 Other iii Delta Depth of Grout Seal Type of Grout <br /> i I ImUation —.Approx Depth I 1 Eastern Surfaca Seal installed by <br /> Report Work Done L3 Type of Pump H P State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION 1�I DESTRUCTION IX(No septic system permitted if public sower ds <br /> available within 2W feet I <br /> • installation will serve Residence_ Commercial— Other <br /> Number of living units Number of bedrooms <br /> Character of aml to a dopth of 3 feet A. Water table dept t <br /> SEPTIC TANK 13 Typo/Mfg capacity2a4i a A , No Compartmar is <br /> PKG TREATMENT PLT Ll <br /> r Method 'rt Disposal <br /> Distance to nearest Well ARL— Founda,ron Property Line_ <br /> LEACHING LINE 0 No 6 Length of lines _ � �� _ Total length/size S � <br /> FILTER BED 0 Distance to nearest Well Foundation Property Line ` <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby .enify 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 OF licensed agent t signature certifies the following I certify that in the performance of Tho work for whish this permit a issued i shall not' <br /> employ any person in such manner as to beccwne subject to w,rkman s compensavin laws of California :ontrsctoes hiring or sub-contracting signatule <br /> di <br /> canes tho following I certify that in the performance of the Werk for which this permit is issued i shall employ persons sub,ect to workman a compansa <br /> tion Iowa of California" <br /> The applicant must d.a11 for ail tie apeclions Complete drawing an reverse side <br /> Al <br /> " nod - ___-- Title _Zt7y1 toN M.r✓'mac-t .lkre}•Date 0 <br /> fJ f> tfNENT USE ONLY <br /> Application Accepted by • Hate Area <br /> Pit or Grout Inayaction by Date Final Inspection by _ Date <br /> \dditronel Comments <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, ftvirommental Health Permit/Services <br /> 1601 E Aattelton Ave , P 0 box 2009. Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT OUE -UNT REMITTED Ck 47 <br /> rAqwj R CEIV D BY DATE PERMIT NO <br /> Edi 4. 3S (:1I river . p� f 0-0 <br /> km .4�a f�"� <br />