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APPLICATION FOR PERM . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Is made in cocpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �� <br /> Job Address �' M�`/( �'-^` r� City LodLot Size/Acreage <br /> Owner's Name <br /> AIZ, t/'"`1—_7ff1M7 Address Phone ' <br /> Conti <br /> aclor ?c>�,�yGQ ,rater" Address/Z; License No. Phohe <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O ' '1CL�/�!yJ�/,�' OTHER Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP�S'fR" & PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> G Domestic/Private Cl Gravel Pack O Tracy Type of Casing Specifications <br /> Q Public Other O Delta Depth of Grout Seal � � Type of Grout J <br /> ❑ Irrrpauon _ Approx. Depth ❑ Eastern Surface Seal Installed by <br /> /pepair Work Done 0 T pe of Pump H.P. State Work Done _ <br /> / <br /> Well DestructionG O Diameter �y> Sealing Material Depth <br /> ✓ //l� pr Depth < Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIRIADDITION I, DESTRUCTION Ci (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 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line S <br /> PAYMENT <br /> SEEPAGE PITS 11 Depth Size Number 1:%='' p"1��C <br /> ..t-r.... E . <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> V 7 t 1 <br /> I hereby comity that I have prepared this application and that the work wilt be done In accordance with San Joaquin cf)6Ayoid1tlitllicbi"stdfe,J34s, and <br /> rules and regulations of the San Joaquin County P .!:,; ;��.L i". a,-A ii-tS <br /> Home owner or licensed a ant's signature certifies the following: "I Certify that in the performance of the work to?,y�hich:this peT it isosbupd,;i xha4lmot <br /> �_ <br /> employ any rton in Ch manner as to become subject to workman's compensation laws of California.' Contractor's hvrng or sub-contracting signature <br /> certifies the llowin . "I rtify 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 o alifor <br /> The applica m t ca to a qulred inspe, tions. Complete drawing on reverse side. <br /> Signe Title: ��� �� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Arco e y Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: JL=�4 _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES tJ <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �j <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, ST(Y'KTON, CA 95201FEE <br /> ��/ 5 f <br /> NFO AMOUNT DUE <br /> /� AMOUNT REMiT7ED CASH RECEIVED BY DATE PERMIT NO. <br /> • EH 1371(ItEv. n 5) }� <br /> EH -4-20 CCCJJJ / <br />