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APPLICATION FORPERMIT <br />SAN JOAQUIN • <br />ENVIRONMENTAL. DIVISION <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />1• 468-3447 <br />.•• DATE USUIM <br />(Complete in Triplicate) <br />Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application ie 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.L (��?Bf y`� <br />i -b Addr.aff <br />ai q q q S USTL fl f�. L..I Citv . J C YI Lot Size/Acreage I eDA'r' LP.,. <br />___ ..�_'_P0. <br />7BOX 6334 <br />Owner's Name <br />YID Address, (t*QC CA,�J7-0 16-1 — Phone (2(-e <br />RECEIVED BY <br />E C5-4 9o9 <br />Contractor <br />Address C-KrO" CA License Noa122AII Phone'463" g 12 - <br />TYPE OF WELL/PUMP: <br />NEW WELL O WELL REPLACEMENT r1 DESTRUCTION Cl Out of Service Well 15 - <br />PUMP INSTALLATION O SYSTEM REPAIR O OTHER"15K S ' itorring WellC <br />PUMP <br />DISTANCE TO NEAREST: <br />SEPTIC TANK!2-Q SEWER LINES'i DISPOSAL FLD ®"5® PROP. LINE <br />FOUNDATION a aU AGRICULTURE WELL 'Z 50 OTHER WELL'; -P-5-0 PITS/SUMPS >,,5PF, _ 1 _ <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 8 - I e <br />r.1 Industrial <br />` <br />U Open Bottom O Manteca Dia. of Well Excavation M A Dia. of Well CasingLUB <br />U Domestic/ Private <br />0 Gravel Pack 0 Tracy Type of Casing N [- Specifications""' <br />0 Public <br />VI Other 0 Delta Depth of Grout Seal __ Type of Grou&Z <br />CI Irrigation <br />_ Approx. Depth 0 Eastern Surface Saul Installed by <br />Repair Work Done U <br />Type of Pump H. P. State Work Done _ <br />W 11 D• ruction ❑ <br />Well Diameter iL Sealing Material i Depth <br />j �(I <br />l,rT <br />Depth _ Filler Material i Depth <br />TYPE OF SEPTI WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence — Commercial _ Other <br />Number of living units: <br />Number of bedrooms <br />Character of toil to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT, <br />Cl Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />L1 No. 6 Length of lines _ Total length/size <br />FILTER BED <br />0 Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />11 Depth Size —_ Number <br />SUMPS <br />LI Distance to nearest: Well Foundation _ Property Line <br />DISPOSAL PONDS <br />❑ <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, 1 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 applican at all lot all req . ad ' pections. Complete drawing on reverse side. <br />e-- <br />Signed X S Title: -� � _� Date: <br />�j r �1 FOR DEPARTMENT USE ONLY 1 <br />Application Accepted by Date 6f11119117 ZT Area "Z / <br />Pit or Grout Inspection by Date Final Inspection by`= , z Date 'r l0 <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 O BOX 2009, STOCKTON, CA 95201 <br />EF+ 192! 1PEV. 1iw31 <br />roe 'e_" <br />AMOUNT DUE <br />AMOOUNNT REMITTED <br />CK <br />RECEIVED BY <br />DATE <br />yIINFO <br />pPERMI7'N0. <br />