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g - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445pNOSJBOX 2009�NSTOCgTON(?CA) 420 <br /> 95201 <br /> pggNlT F,%PIRES 1 Y FROMD U <br /> (Complete in Triplicate) <br /> Application is hereby msde,to gsst,Joaquin county for a permit to construct and/or install the work herein described. This.,- <br /> 11DP OR 1 D2.0 a/� ' 7 <br /> application is made in cestpliance with San Joaquin County Ordinance No. 5k9 and 1862 and the Rules and Regulations of I <br /> Josquin County Public health Services. I Lot Size/Acreage <br /> it, a C i I y <br /> Job Address O s <br /> Z7 � � C Phone <br /> L� Address --L'5 <br /> Owner's Name �� _ '7�'JZ'-�6 <br /> License No. 3 �S �--- Phone <br /> Contractor �- iLc/ i r Address <br /> i WELL REPLACEMENT ❑ DESTRUCTION ❑ put of Service Hell ❑ <br /> NEW WELL ❑ OTHER`❑ Monitors 1 Hell <br /> TYPE Of WELLIPU P: SYSTEM REPAIR i;ktM7 <br /> PUMP INSTALLATION 13 <br /> SEWER LINES — — DISPOSAL FLD.� PROP• LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ��� OTHER WELL PITS/SUMPS <br /> AGRICULTURE WELL <br /> FOUNDATION +' <br /> PROBLEM AR - <br /> INTENDED USE TYPE OF WELL EA CONSTRUCTION SPECIFICATIONS yS Dia" <br /> l A,,r <br /> f Well Casing l r <br /> Dia. of Well ExcavatioT�--- J� <br /> El Industrial pen Bottom ❑ Manteca. - I Specifications <br /> ❑ Tracy P Type of Casing_ <br /> Cl Domestic/Private ❑ Gravel Pack -"Type of Grout <br /> - --_ -" -r.1'aUier �" ,..n Datta �, `"`Depth of Grout Seal- J I <br /> I'?P`ibkc Surface Seal Installed by <br /> �rrigatlon ..._._.Approx. Depth I 1 Eastern: state Work Oona <br /> - of Pump <br /> Repair Work Done ❑ Type Sealing Material i Depth <br /> Well Destruction 0, Well Diameter' ;]Filler Material a Depth �rIY= � <br /> Depth <br /> TYPE Of SEPTIC WORK"A NEW INSTALLATION I 1 REPAIRJADDIT40N i I DESTRUCTION I I available�w'thin 200 fee;��ed if public sewer is II <br /> � �, 1 <br /> 'Installation will serve: Residence Commercial f Other <br /> Number of living units: Number of bedrooms Water table depth <br /> ` Character of soil to a depth of 3 feet: [ Capacity^�-- No.Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.❑ -Property Line - <br /> Distance to nearest: Well I Foundation <br /> lTotal length/size <br /> i LEACHING LINE ❑ No. 6 Length of lines Property Lina <br /> FILTER BED Cl Distance to nearest: Well � Foundation <br /> r i y <br /> 1Size Number <br /> 1 Depth <br /> SEEPAGE PITS j , Property Line <br /> SUMPS Cl., ,Distance to nearest: Well Foundation <br /> DISPOSAL PONOS ❑ ! + <br /> i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws,`and <br /> rules and regulations of the San Joaquin County <br /> rmance of the work for which this permit is issued,t shoal not <br /> Homs owner or licensed agent's signature certifies the following: "I certify that in the pe <br /> rfo <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Co'ntractor's hiring or sub contracting signature <br /> certifies the following "I certify that in the performance o e work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of C11111111Oral <br /> The applicant mu requir ns ion Comptete'drawing on reverse ide. <br /> }I Title: A �'� Date: <br /> 5i4Md t _ i <br /> FOR DEPARTMENT USE ONLY <br /> t Date!� L — Area <br /> Application Accepted by <br /> i I. Date Z� 2 qZ Final Inspection by Date <br /> I Pk o Grou pectbn by <br /> Addhionsl Comments: gas, 1��,zurdt - <br /> a /U N <br /> r Applicant - Return all copies to: EnvironmentaloHealthuPermit/$ervice6viCe's r • <br /> 445 N San Joaquin, p O Box 2009, Stkn, OA 95201 <br /> s <br /> CK REc IVSD <br /> IY OA E PERMI7,NO. <br /> } <br /> FEF <br /> O AMOUNT DUE AMOUNT REMITTED c <br /> . EH 13.2 t11EY:W'sr r <br /> EH r1-76 <br />