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ABPLICATION FOR FSMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> E"IRONIISIITAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-342 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (Complete in Triplicate) <br /> Application is hereby and*,to Ban Joaquin County for a permit to conetruet and/or install 1he work herein described. This <br /> appUz*t1cm is amQ* is caplianc* vith Sen Joaquin County ordinance No. 549 and 1$62 and tt it Rules aad Regulations of San <br /> Joaquin County Public Health Services. �7 / <br /> Job Address l yno o A'„ 1a,1 �i City l�an;;i� Lot itst/Acreege I /KL2 <br /> S6-a <br /> tAJA- <br /> o_wnw I Name /I'J"- 01— Cjg2_ Address 2737 W.C `79/ /2.333. <br /> F& 6`Il0 <br /> Conttactor��ui IVB D^ ti ,. � dtess�7SLPp Qrl. -Z-Ae f_ kkt'3=vqA )CI-cen No 003 Phony <br /> TYPE OF 1NEt�P: NEW WELL C WELL REPLACEMENT C1 DES Fly TION Cl Out of Berrie* Well Ll <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 7 Sad ER Monitoring Krell ❑ <br /> DISTANCE TO NLAREST: <br /> SEPTIC TANK ,^ SEWER LINES ` DISPOSAL FLD. PROP. LINE <br /> r� j FOUNDATION AGAICUL'TURE WELL 4160cAOTHER WEL PITS/SUMPS ��• <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 IndustrialC3 Open Bottom 0 Manteca Dia, of Vfth-Excovsiken ^- Dis, of well Casing <br /> C.1 Domani/Priv/to 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> VI Public 1:1 Other n Delta Depth of Grout Sea] �� Type of Grour lea <br /> I I Irrigation —.Approk. O*pth t 1 Eastern Surface Seal Installed t y +� <br /> Repair Work Dons L7 Type of Pump H.P. State Work Don _ <br /> WON Dgttuction CI WON 01amatst Starling Material b Depth <br /> Depth tiller Natarial i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic ystem P*fmitted if Publit sews, is <br /> available thin 200 fact.? <br /> Installation Witt serve: Residence Commercial— Other <br /> NumbM of Nviniii units: Number of bedrooms <br /> Charater of a*to a depth of 3 lom: __ _Wat Ib <br /> SEPTIC TANK Cl T"WiMfg Capacity No. <br /> PKG. TREATMENT PET. 0 Met '-0t4 s+ ... <br /> Distance t0 noomt; Well ,i,� Foundation Property <br /> J <br /> � J'JF4CJ I i,t,{,t4TV <br /> LEACHING LINE 0 No. & Length of lines Total lengtp(y� R <br />' FILTER BED i O 01stsnce to nt]er*st: Well Foundation <br /> SEEPAGE PITS I I I Depth Sire � Number <br /> SUMPS ffI LI Distance to nasrast: Well. Foundation— Property e <br /> DISPOSAL "t S E3i <br /> I Gari• that I h6W fed Shia a atfon arta Inas ine wort v iii ue iwl,f«,64rv,\-i.1.Y . �. - ---• Incas: <br /> lisnby dY 1?tepa PPes C' '••.^"!�^ •state laws, and <br /> OAS*and raqulst of the San Joaquin County <br /> 1,10"Ovwitr Or�d"&W$Signature Certifies Lha folowing: "I wify than in the performance of the work for which this permit it iaauad, I shall not <br /> antpby any Persian in such monnar sit to bsaenta subject to workman's compensation laws of California." Conti 1010ea hiring or Sub-contrUtihq aipnaturs <br /> tlsftiliss tans follotvkw #I asftity that in the psidormanos of the work tot which this permit is itaued, I shall amplo persons subject to workman's contpensa- <br /> 1 tion hers of comorftia." <br /> The sppYCattt Oilst c411 for all required IrmMnlions. Complete drawing on toyer" aids. <br /> S _ow" <br /> Tltls: r Dole: <br /> EMIT USE ONLY '0% <br /> Aye �r <br /> Applkaetion Adapted by7Dau a <br /> Pit of afoul Wap~by Data0,7 1P-'—f:inal Inalmtion by Dat <br /> Add?kww Cotttrrtants: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Perasit/eervicas <br /> r 448 N San Joaquin, P o Box 2008. Stkn, CA 962GI <br /> INFO AtMQtJHT tkl5 AMOUNT AEtAtT7ED jtiN RECEIVED SV DATE PER6alT N0. <br />