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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. Y%tq <br /> ENVIRONMENTAL HEALTH DIVISION ieA <br /> P 0 BOX 2009, STOCKTON, CA 95201 rjy- <br /> (209) 468-3447 0 C T 1 3 19-02 <br /> REMIT EXPIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby uLde.to San Joaquin County ror a permit to construct and/or install the work herein described. This <br /> application is zwLde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulea, and Regulations or Ban <br /> Joaquin County Public Health Services. <br /> Job Address 260 &J. Mal in 5--f city tt4aylf eCe/- Lot Site/Acreage , 2-5A <br /> Estate o f ,4.,Icic, C(15Q Z ZLO- 1. Phone 641�-)SIV,-06-3 <br /> Owns('& Name — Address 5-�o • <br /> 05-fe rb e Y-,I- f --7:523 RtueV-)2 <br /> .7 r-* T o-- Address. Morde�±Q CA 'f:Y3�Tl <br /> Contractor S+eWL _License No.4-4(,�-70 . Phone,537-5767 — <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION o out or Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK IVIA- SEWER LINES DISPOSAL FLO.AZI± PROP. LINE <br /> FOUNDATION 30 ' AGRICULTURE WELL 6�4— OTHER WELL222 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom Ck Manteca Dia. of Well Excavation Dia. of Well Casing 2 <br /> 0 Domestic/Private 9 Gravel Pack 0 Tracy Type of Casing-w6 Specifications <br /> (7 Public 11 Other 0 Delta Depth of Grout Seal Type of G(our�-,; �rll- Le,4— <br /> C1 Irrigation —Approx. Depth 0 Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> W411 Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION 10 REPAIR/ADDITION L1 DESTRUCTION CJ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 loot: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl <br /> Method of Disposal <br /> Distance to nearest: Well Foundation— Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to no 77— <br /> arest: Wall Foundation— Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ul Distance to nearest: Well Foundation_ Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby candy 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 lh4 Son Joaquin County <br /> Home owner or licensed agent's signature conifies the following: -I conify.that in the performance of Ins 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 Calito(nia." Contractor's hiring or subcontracting signature <br /> conifios the following:"I conify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The spplican;.n?ust c 11 for qu d 'ins Itio a. Complete drawingever6o Side. <br /> /Opy 7 <br /> Signed f Title: Date: - 7 / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Pit or Grout Date -93-6 <br /> i,rispection by Date Final Inspection by Area Date—LL —a— <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 2000, STOCKTON, CA 96201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMI-rNO. <br /> -S,3 g- °° 4 847 SO— <br />