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APPLICATION FOR PERMIT <br /> f� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> MIT ESP RES I YEAR_PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby ma4e to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance 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 Z is W95T W&Alkliw= - .City Lot Size/Acreage`Com• X <br /> -.} <br /> Owna's N e 'F,L Address _t�ar:tc iSCQ, a u+tomPhone <br /> �lF' iu�T�t 1,, (� <br /> Co lraclor � _Address a� Z IhLD�V�Ut�WlE7E License No. y 4 PhJg1_ � ���� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ '-SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X <br /> DIST±NCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL DISPOSAL FLD PROP. LINE <br /> FOUNDATION AGRICULTURE WELL \v�L OTHER WELLQ PITS/SUMPS _M- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C� industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia, of Well Casing 11 i <br /> Oomssti Private -.Gravel Pack ❑ Tracy Type of Casing Specifications&AF-0. go <br /> q Public 'k�Olher Z Delta Depth of Grout Seal �`�rF Type of Grout awffit i6ent" <br /> M Irrioation F .Approx, Depth b Eastern Surface Saul Installed by tiE• C• - -- ,-- - <br /> i <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Piller Material 4 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION D REPAIR/ADOITION 0 DESTRUCTION G iNo septic system permitted if public sewer is <br /> available within 200 feat.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedroom& <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> M <br /> PKG. TREATMENT PLT. CI Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1No. & Length of lines Total length/size r <br /> FILTER BED n Distance,to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation } Property Line <br /> DISPOSAL PONDS ❑ " <br /> I hereby cenify 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 thal 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 compensa- <br /> tion laws of California." <br /> The applicant must coil for all required inspections, Complete drawing on reverse side. <br /> Signed.4 Title: 1 ]S� Date: 10'30�g l7 <br /> [ztk��een rLkP FOR EPARTMENT USE ONLY <br /> Application Accepted by / Date ^6317v Area <br /> Pit Grout l spection by Date[ =r 4`-�'C�Final Inspection by Date 0 <br /> O <br /> Additional Comments: ,a <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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK IT RECEIVED BY DATE PERMIT NO. <br /> INFO �( CASH <br /> . EH A.,V 114", h s! <br /> ���j V �M t��� !J G V�✓ wN <br /> I <br />