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` APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI S ' <br /> E"IRQN)IIBNTAL BRAT TH TIIVISION <br /> 445 N SAN JOAQUIN. PHONE (209)46$-342 <br /> P 0 BOX 2009, STOCKTON, CA 95201 j <br /> i <br /> (Complete in Triplicate) <br /> d <br /> Application 19 hereby Made,to 63aa J <br /> oaqulo County for s permit to canetruct aAd/ar, inrta,l], the nark herein described. This ' <br /> aypllcAtion is made is cmVILlauce with .Ban Joaquin County Ordinance No. 549 and 16W and tt,g Rules and Regulatione of San <br /> dosquin CoM1W.Publ1e Health services. <br /> Job Address��.;,?t.-C_�r(CIsf.Q&;4z' Ye City Lot ise/Acreage <br /> Owner's Name �r CD Addtes2Pho <br /> rv.cp or o s i�F 69ro �/o) 5/63`P12 <br /> Contractor Cq&411Address 2 u L We No, Pham �g 1 <br /> TYPE OF WELL/RUMP; NEW WELL C3 WELT. REPLACEMENT Cl DESI <br /> o Out of service Well <br /> PUMP INSTALLATI0 © SYSTEM REPAIR C75o�f dK Monitoring Yell nDISTANCE TO NIAAEST: SEPTIC TANK $EWER LINES 7 01SPgSA'L FLPROP. LINE�FOUNDATIONAGRtCtJLTURE WELL.1�(yknSr,170TItER WELtPITS/SUMPS <br /> INTENDED U$E TYPE OF WELL PROBIEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 industrial ' CJ Open Bottom AMameca Dia, of Well Excavation� Oia, of Well Caring N <br /> I-1 DontuticiFfivits © Gravel Pact 0 Tracy Type of Casing_ �� Specifications <br /> Public Cl Other - n Delta Depth of Grout Seat ` Type of Grout `!e''tm <br /> I <br /> I ! Irrigation —.Apprpr<. Depth I I Eastern $arises Seal installed by , <br /> Repa'a Work Donn V Type of Pump H.P. Sts a Wor don e <br /> Well ClMfuction ❑ We" Diamatrir se"ing Natsrial a Depth Ir A <br /> Depth - 2'iller Material ti Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l l REPAIR/ADWTION I 1 DESTRUCTION ; i INo septic gyflern permitted if public sewer ir< <br /> i available 'thin 200 Ieet.I <br /> Installation vola verve: Rtlsdenae�. Commercial— Other <br /> Number of 11vinp unite: Number of bedrooms <br /> - Chareater pt soll to 0 depth of S tact: Wati f tabla depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity „" No. rtments <br /> PKG. TREATMENT PIT, ❑ Met of Disponi <br /> t. a <br /> Distance to neanet: WON _ Foundation_ Property Lii is ., <br /> Cy <br /> LEACHINCI LINE Cl No. 6 Length of tines Total length/size <br /> FILTER SED i C] <br /> Distance to nearest: Well Foundation Property L no L <br /> SEEPAGE PI'E'S I, I I Depth Siwe Number <br /> SUMPSJJ Lt Dietusn rry cs to nearest., Well Foundation PropsIn <br /> DISPOSAL PONIbS 0 ? <br /> !hereby oanHy I ha*prepared this applleelion ane inat the wwR vrnl im:wim:...�:;„;,:-,�, ;::;.CF.= � .-. �......u,, state laws, and <br /> tales and regtAlWis of the San Joaquin CouatV <br /> hlW"owndr or Ncsnlad&WWI dignsturs 0"fies the following: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> y any fiMedn in each manner ea to b000ms subject to workmen's compensation lows of CalifWn;A." Conti wtoes hiring or subcontracting s*wtura <br /> ssrtlfl O the follovrktg; "I certify that in UN Wormsme of the work far which this pwrrilt is Wumd, I shall smpia persons subject to wopansa- <br /> rkman's com <br /> don laws of Com'W"1111-11 <br /> ' <br /> The aYpYCMttrhWl a for aN inepectiona, Complete drawing on reverse side. <br /> Sir"X } T <br /> DEPARTMENT USE ONLY ' <br /> Applin;#tbn Aoospted by Date <br /> Arqp- <br /> Ph or afoul lr»po"Wri by Date �Z Final Inspection by pats <br /> Addkkmo Comments: I <br /> APPliosnt - ltetarn all copies to: sae Joaquin Country Public Health Services <br /> Environaental Health Permit:/Services �F <br /> -} 446 N San Joaquin, P O Box 2000, Stkn, CA B52 1 <br /> FEE INFO AMOLMT DUI AMOUNT REMITTED �$1 r RECEIVED BY DATE PERtrltr MO. <br />