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,p r- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> h- .�. 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCff", 'CA 95201 <br /> IIIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby asde•to San Joaquin County,for a permit to construct and/or install the work herein described. This <br /> application is node in caspliaace with San Joaquin County Ordinume No. 549 wA 1862 and the Rules and Regylations of San <br /> Joaquin County Public Health Services. <br /> Job Address*10 ZS-"g^S rDtj (�D City 60/ Lot Size/Acreage /aa jAC <br /> Alto.),v f+ME/ Ni A� SA)"r Phone1 3C <br /> Owners Name Addres/sCs <br /> Contractor f Address •�7�'t License No.-� �' Phone y, <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION O Out of Service Veil <br /> Monitoring Vell <br /> RiMP INSTALLATION W SYSTEM REPAIR O OTHER O O <br /> DISTANCE TOWEAREST: SEPTIC TANK I SJ t SEWER LINES DISPOSAL FLO.iSO 7 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> CI Industrial Oi Open Bottom O Manteca Dia. of Well Excavation ty Dia. of WON Csskv- <br /> *.Oomestie/Private ;Gravel Pack O Tracy Type of Casing 0ii�. Specifications �l�f a <br /> t'I Public iO Otfisr (l Delta t Seal 'L.ei Type of Grouter CCJPL!Z z <br /> 1 1 Irrigation. Approx. Depth 1 I Eastern Surfsca Suit"taNed by Q► <br /> Repair Work tions f —\Type of Pump M- bLft: ;1 ` gats Werk _ <br /> WellDion O_..-Ws Oitmsts4- __:�h,` lag';Material i Depth <br /> Depth � <br /> M r tenial i Depth <br /> TYPE OF SEPTIC WORK: New INSTALLATIOf0 "REPAIR/ ODI ION I I DESTRUCTION I 1 1 o septic i oystern par ted if tblic sewer:is h'1 <br /> -- silable"hin 2004set.l <br /> Installation will serve%-41oek"_ Commercial_ Other i <br /> Number of Nving truer-L— Number of bedrooms ! <br /> Charaelsr 0#04 to a Okoh of 3:fw: --w water�Iabls depth <br /> SEPTIC TANK. OTypf/Mfg Capacity No. Cer"Itments <br /> PKG. TREATMENT PLT.O '� r _ i�'". Method of Diipasil <br /> Distance t� 1Vl/alt Foundation Pi operty Line <br /> LEACHWG LINE 'Ll ,'No. 8 Length of lines Total leth/size <br /> FILTER BED O rOiatance - , ell Foundation P�opefty Lias Ilk <br /> SEEPAGE PITS I 1 i Depth Number <br /> SUMPS LI I Distance to negro': "-We-r- — Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have piepared this appktition and that the work will be done in accordance with San Joaquin county-oldig(mes, state laws, and <br /> rules and regulations of the 3m Joaquin county <br /> -- Home owner or licensed agam's signature certifies the following: "1 certify that in the performance of the work for , h this permit is idled, I shall not <br /> j employ any parson in such as to become subject to workman's compensation laws of California."Contract..OL IIS co g��rs <br /> csrtifin the following:"1 ca tify that in the performance of the work for which this permit is issued,10011 employ ps subject tte won rntat's compinsa- <br /> tion laws of CaNfornis." <br /> The applimantt must call f raN ed Insppations. Complete drawing on reverse side. + <br /> �/ u <br /> Signed x Title: 2)&XA-uft \\Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> 7 <br /> Pit or Grout Inspection by ate I_2� 1z Final Inspection by f-� �� Date <br /> ,�. <br /> Additional Comments: - <br /> o �t 5 <br /> Applicant Retufrn all copies to: San Joaquin County public Health Serve <br /> -- -s...,...�,....._..w,....r._.__N_._.,.,_..w_.:._._Snalitlnaleat-al.•` ATViCes <br /> 448 N ne.�oaquin P O Box 2 <br /> �rA, CA 852©1. <br /> r- r' <br /> 'g AMOUNT DUE AMOUNT REMITTED K RECEIVED ftY PATE PERMIT' <br /> JrN_F.O/ CASH <br /> IaEV.V e 51 W N O �o�w ` �. /� <br /> EH W36 lT:1 -610W <br />