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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL aEALTH DIVISION <br /> P O BOX 2009, STOCXTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES I YEAR OROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. Thie <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1962 and the Rules aztd Regulations of San <br /> Joaquin County�Public Health Services. <br /> VJob Address 7 S • �G,IZ/ �f h'f r. City S,S C• Lot Size/Acreage 129i`tt 2, <br /> R.Owner's Name 18 r1 ktir� "�1Arf VIJ r Address 19 / -7 e-1 �1 �yTl+�f' Phoney <br /> t <br /> KConlraclof l���uv.��. _Address License No. Phone <br /> T PE OF WELL/PUMP. NEW WELL Q W L REPLACE NT n DESTRUCTION 0 Out of Service well L1 <br /> PUMP INSTALLATION U YSTEM EPAIR Cl OTHER O Monitoring well L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C 57 CTION SPECIFICATIONS <br /> t-� Industrial O Open Bottom Manteca <br /> is. <br /> of We Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack 13 Tracy Type of Casin Specifications <br /> ED Public fel Other ❑ Delta Depth of Grout eat Type of Grout <br /> ErnOetion ^.Approve, Depth d Eastern Surface Seal insta d by <br /> Repair Work Done U Type of Pump P. State Work Done_ <br /> Wall Destruction O Wall Diameter Sealing Hat-trial & Depth <br /> Depth Tiller Material 4 Depth \� <br /> y� <br /> T E OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION 0 DESTRUCTION 0 lNo septic system permitted it public sewer is \ , <br /> /Y available within 200 feet.) v <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> i Character of soil to■ pth of 3 feet r Q Water table depth 70 <br /> SEPTIC TANK Type/Mfg ( rJhCP/+ Capacity ���d=:q No. Compartments <br /> KG. TREATMENT PLT.C1 + I Method of Disposal <br /> Distance to nearest: Well F Foundation 20 Property Line <br /> f 100 <br /> LEACHING LINE O No. 8 Length of lines Total length/size <br /> I FILTER BED Q Distance to nearest: Well Foundation d Property Line <br /> h <br /> I r <br /> t SEEPAGE PITS ,(I Depth S Size It r� Number <br /> SUMPS LI Distance to nearest: Well S�?lFoundation Property Line �dG� <br /> DISPOSAL PONDS O <br /> 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenza• <br /> l' tlon laws of California." <br /> f <br /> T - <br /> applicant fnust call for all required inspections. Complete drawing on reverse side, ,, <br /> i Signed Xec tet- � Title: �.�e_,r Date: 1&2 ZZ <br /> f OR DEPARTMENT USE ONLY <br /> Application Accepted by C'.�C.,_ `Vl, o, Date ID as <br /> E Pit or Grout Inspection by Date Final Inspection by - Dater' <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 2008, STOCKTON, CA 85201 <br /> FEE <br /> NFO MOUNT DUE AMOUNT REMITTED LASH CK RECEIVED BY DATE PERMIT NO. <br /> . E>t 13.24IREV.i/ee> <br /> 67 ICTcJ (:�,k <br /> r ' <br />