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APPLICATION. FOR PERMIT <br /> Y PUBE <br /> SAN JOAQUIN COUNT"� iC HEALTH SERVICES <br /> ENVIRONMENTAL REALTH .-DIVISION <br /> 1 E. HAZ <br /> ELTOWAVE. , -P'H d' (200468-3420 <br /> P 0 BOX,2009-.,IqSTbCK.TON.',OC'CA' 06201,t:'l c iiCrl 1 s =BSc lu Jfail <br /> riIIllPERMIT1 EXP.IRES-jl�JYEAR r.FR0HeDATR?.,1,S 8 <br /> (Complete in Triplicate) ;t:, <br /> n COU'A . and/off'Initall-the work her�dn d.4�scribed.­ This <br /> Application Is hereby made:to-San' dn -a i)e'imit�to'&onstrudt <br /> I— ) 6 n <br /> con�liance;., -.0rd1:neLricef.No�'_5,4r9 iand��8 2 of,;San <br /> application is made in4con�liance;.c.e.a h-gan UC�jquih,­C&nfi�' <br /> Es z-�ql.t�vv io 116t"Si1e/Acreage"", <br /> c Heal#L se &F!'I no 1--, ('a fl <br /> Joaquin County Publi Z; uilrw 1�2�t i" <br /> 6"T_8 <br /> Job Add., 12 41 <br /> Owner's Phon <br /> . Name r6.. ddr <br /> S. <br /> G. <br /> i,-e <br /> "Addresi--PIL Y-T�2 2- <br /> ft�o o-Yi <br /> Contractor n <br /> --.Pho;e <br /> _QIEST�BOTHER <br /> Cof Service'Well D <br /> TYPE OF WELL/PUMP�_ !.NEW,0ELL.C3. ll� ... . <br /> M P ELL-REELACEMEN.T-0-- ION 0 0-ut <br /> . OL ' ' mc�'n oring Well L7 <br /> SYSTEM OTHER ❑C1 <br /> PUMP INSTALLATION ❑0 <br /> AN P._LINE­11­ <br /> DiSTANCEi TO NEAREST:-SEPTIC'f K - <br /> SEWER-LIN <br /> I R WE O1-HERWECL_ PITS/SUMPS-L—:_ <br /> FOUNDATION. ru�nl <br /> RUCTION SPECI <br /> IF WELLCO. 'FICAiTIONS <br /> INTENDED USE :TYPE 0 L PROBLEM CO <br /> n Industrial 0 Open Boitom 1 El Manteca Excavation` Dia; of Well Casing <br /> —0--Grovel-Pack -L--.L. <br /> EI Domestic/Private-- _L 11-Trac - . lg <br /> y- <br /> 1:1 Other n Delta of Gro6t Skil <br /> I') Public Dept Type of Grout <br /> I I Iftigation A�pprox. Depth I I Eastern Sul :0 Seal I nst ailed_by._! <br /> I/L11 <br /> _-Atate- <br /> Repair Work Done L7---T ype of-Pump- H <br /> k <br /> Well Destruction 0' Wall Diameter Sealing' Mate til & Depth,'— <br /> r <br /> ITE -X—D;iit <br /> D&p1h �le h 't--1 <br /> TYPE OF SEPTIC WORK:----NEWiINSTAILLATION­ !-T-ION-(-4--;-[)ESTRL4C-T-ION-1-14(No-septic,system-0ermiftbd-if-publicso' -is <br /> 101�i-REPAIRIA-130 war <br /> j !avail6blewithin2001feet.11 <br /> C <br /> Installation will serve: Residen-ce .0-MM6 rcla r <br /> Number.of living units. __��qHber of bedrooms E <br /> Cha <br /> r-a-c'te' .1 r of sail to a depth ff0A0 A 'A 1___]_Waier table do <br /> 'pth T-_ <br /> SEPTIC TANK 9 <br /> -Type M1 4 --Capacity Compartment's(i <br /> Method f D' opal <br /> P <br /> PKG. TREATMENT PLT. <-) I ,- - -, <br /> Diitance to nearest: r eny <br /> Li <br /> Foundation <br /> LEACHING�LINIE No.-&-Lengih of lir�es I a s <br /> Jovdy �gth/s <br /> TOXJ <br /> Wait Property Line-1 <br /> FILTER BED Cl I tance to nearest: <br /> -4­ <br /> SEEPAGE PITS I 1 79 N' bar i <br /> _iDepth ' opb'rty Line <br /> - Distance to'near lst:: I we A:A h '.oundation, <br /> SUMPS <br /> DISPOSAL ePONDS <br /> I hereby certify that I hive Rripa4d thii application and that_thp !be clone in acc6r(jan'ce_wiih San-Joaquih.county-ordinances' stat6lawsi•and.--i <br /> k fl <br /> rules and fegullations of,the San Joaquin ounty <br /> Homeowner or licensed agent's sib nature certifies the f I r!Lfy thp.L in the t performance of the Work�f 6r_-Avhich:this-permit-is issued,.I_S�alt_not_ <br /> r , " I rri <br /> employ any person in such manner as to become subject to workman's coponsaition ilaws!of California.'.' Contractor's hiring or sub-,contracting signature <br /> certifies the following: "I certify the I t in the performance.of the wotk forhic'h_Jhis'pe(mit_isJs0 <br /> ,w . . c't-to.work(�an's'.componsa-----i <br /> -. .uecl,-,I,.f$681i-impl�ipers�ons.subje <br /> tion la�vs'oU California."',, -4 1 1 1 <br /> The appficapnnukk call for.. quire Inspectioni. Compl.a-drawing on-reverse <br /> V r7 <br /> --Z------ Dato_­� <br /> Signed <br /> 1,0111-DEPAR <br /> �4 r_LISE-0"Ly-_-1­_- <br /> If T JT- <br /> All _Date <br /> Application AccepI4d by I <br /> f I �L <br /> Data al-Inspai. <br /> Pit or Grout inspection by .-Fin Diion-by_ 13411-6—n. <br /> Additional Comments: <br /> Applicant Return LU copies to., San Joaquin County Public Health <br /> i _.Servic;es-;-'Envf�ronment&i- <br /> 1601 E. Hazelton Ave.. P O;Box 2009, Stockton, ;CA 95201 -1- <br /> CK# I <br /> FEE I NO.AMOUNT DUE AMOUNT REMITTED I PATE' PERMIT <br /> INFO CASH RECbVE6 BY P <br /> 1% <br /> -24(ACV <br /> EH 13 ---1. <br /> EH 14,26 4J.C6 <br />