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" A. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> * ` 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 XX T08 yD--366y"Ca� <br /> 5T. vtn t c iS <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 1s 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 -0&7- /-b, A-1- <br /> r ASa-1Y lav City Sew Lot Size/Acreage <br /> t6-e& /uta r /451#t� L t l Phone �3L7-02-63� <br /> Owner's Name ST. fnrfGn'7� LS G!�-/11NAddress <br /> Contractor NVS 'Vy% ress 7075- E. rn1��72A Sr-License No <br /> �7/z�95 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Q'' er--- Weal—- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Bp)(ja 6S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL f+1T-9i'�FlAtitS� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> I'1 Public Cl Other n Delta Depth of Grout Seal ,. 1rpa-ef6rer►t Nd 61A) 14.�T7�� <br /> I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ ItffnL� �LK6tic <br /> tr <br /> Well Destruction O Well Diameter Sealing Material & Depth 6Lj 6,-j r, <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) v <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L7 No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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, I shall t <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 call for all ed inspections. Complete drawing on reverse side. <br /> Signed X 1 Title: FN6 C60 L-6-61&7- Date: <br /> FO DEP RTMENT USE ONLY /06- �1 <br /> Application Accepted by Date `� �" Area <br /> Pit or Grout Inspection by Date Final Inspection by Date g! Z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> VV­ <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C ECEIVED BY I 4F/TE PERMIT'N0. <br /> INFO <br /> . EM 13.2 (REV.1/"5) CO /� <br /> OP- <br /> EH 11.26 r A6k I YI <br /> i <br />