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APPLICATION FOR PER&d' " <br /> *-di JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,r �luv , <br /> ENVIRONMENTAL HEALTH DIVISION li <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ,P%aIT EXPIRES 1 YEAR VRO►d DATfi T44ttF't) SEP 2S 1990 <br /> (Complete in Triplicate)_ <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the\b1( nark{' <br /> application is made in Compliance with San Joaquin County Ordinance No. 51x9 and 1962 and the Ru es CXllbed. This <br /> Joaquin County <br /> � Public Health Services. RiiNUtlons of San <br /> Job Address / r .,v` City cL Lot Size/Acreage 1yrj <br /> Owner's Name/ rr t- � ,u s Address s�1 rz /� n��- ��V &11-AC,s„PhoneC <br /> � <br /> ,�,, �Avtit.!�+✓r cf!- �•-Sn vc S/ /02! � 5�� �..lo-�r�c� <br /> Contrhttor „r�.rn,.mr�_,Address License No.#.SC/ SGG Phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION XL Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 <br /> fl Industrial O Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ('I Other O Delta Depth of Grout Seal Type of Grout <br /> Irrioation — Approx, Depth O Eastern Surface Saul Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done_ <br /> Well Destruction Well Diameter y Sealing Material & Depth r-t -[(c C-- ,6/y fcµ.o�rc <br /> Depth Filler Material & Depth a('Ow <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 71 DESTRUCTION Cl to septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial__._ Other available within 200 feel.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines <br /> Total length/size <br /> FILTER BED 17 Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS Number <br /> LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Q <br /> 1 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 regulations 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 issued, I shall not <br /> employ any person in such manner as to become*subject to workmen's compensation laws of California.” Contractor's hiring or sub-contracting signature <br /> certifies the (lowing: "I certify 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 ci Celifornls." <br /> The appli an must call for all requi d ins Complete drawing on re rse side. <br /> Signed Title: .�, �/ �,�� ti ! `? <br /> Date: to / y <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t/� Date 9 07 9d <br /> j - i Area —LI-3_�' <br /> Pit or Grout Inspection by Date Final Inspection by_ , Date y.L x y() <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 HOX 2009, STOCKTON, CA 95201 <br /> -J::FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO H RECEIVED BY DATE PERMIT NO. <br />. EH 13•24 IIIEV.iix�i � - <br /> EH N.m <br /> ---y•o .y 7 .1.. ���I`� C�..� <br />