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APPLICA'1I0h FOR PERYIT <br /> SANQUIN COUNTY PUBLIC HEALTH "IVICES <br /> VIRON1dENTAL REAL <br /> TH DIVISI6' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 __ iiEl_lf1 <br /> I P O BOX 2009, STOCKTON, CA 95201 --e l i`'` 'C, ' r­ <br /> PERMIT EXPIRE Y FR 111 I T ;E <br /> (Complete in Triplicate) ::'L. JUL 22 Nr <br /> Application is hereby made to San Joaquin County fors I� <br /> application is made in cowliance vith Ban Joaquin County Ordinance nno 5b9#and 1862eand theRulessadvork eRegulmtionein drsf San <br /> Joaquin County Public Health Services. t <br /> Job Address I . City CJI txK'["O/11 Lot Size/Acreage <br /> } Owners Name C-U.51"A Mq rrN�N�( <br /> Address A71 AP-K . Phone <br /> Phone <br /> r Tfmelyd,CA- <br />{ Contraclor AddressVer— -7 fcense No. Phone <br /> .._,_,., <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Pkout of Service well Gl <br />{ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑J - OTHER ❑ Monitoring xell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL 0THER WELL PITS/SUMPS Y Y <br /> INTENDED USE TYPE OF WELL PROBLEM AiiEA- CONSTRUCTION SPECIFICAfi6NS '- <br /> Cl Industrial ❑ Open Bottom ❑ Mantsca Die. of Wall Excavation DIa. of Well Casing <br /> ti Li Domestic/Private 0 Gravel pack � ❑ Tracy Type of Casing__ Specifications. k <br /> I'l Public 1:1 Other n Delta Depth of Grout Seal i} Type of Grout <br /> II Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Wo Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth T "f20ft. 12 Ft- 9 <br /> 4 Depth Filler Material i Depth <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted R pgrblic sewer is <br /> !I available within 200 lest.l <br /> InstsRat aarw: Residence^ Commercial— Other . <br /> Number of living un Number of bedrooms <br /> Character of sop to a depth of 3Water table depth <br /> SEPTIC TANK. 0 Type/Mfg apacity ii No. Compartments <br /> PKO. TREATMENT PLT.❑ , _ Method of Disposal <br /> Distance to Merest: I ion '� Property Line <br /> LEACHING LINE 0 No, 8 gth of lines Total Is Ize <br /> FILTER BED Cl tante to n"r$st: Well Foundation Property Lin <br /> Ij <br /> SEEPAGEPfT I f Depth Sire Number <br /> i SUMPS l 1 Distance to nearest: Well Foundation i' Property Line <br /> r DISPOSAL PONDS= <br /> c7' <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, state laws, andf <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's iignsturs certifies the following; "I certify that In the performance of the work for which this permit Is issued, I shall not <br /> employ any person In such manner as to become subject to workman's compensation laws of 6111 nit."Contractors hiring or sub•contrecting signature <br /> MINI@$the following: "i certify that in the performance of the work for which this permit is isauetf,I shall employ persons subject to workman's compenss- <br /> lion laws of CmIifornls." <br /> The applkantat can for all requir inspections. Complete drawing on reverse side. j <br /> Signed .�a Title: lJlS, Dete: / ✓ <br /> a <br /> FOR DEPARTMENT USE ONLY !I <br /> Application Accepted by i <br /> r�K Da�s � ,Area <br /> Pit or Gout Inspection by i v <br /> s r G� Final Inspection by "`��` 't DateiL <br /> Additional Commants: X11 I gkA 107A&QL;1 <br /> Applicant - Return all copies to: San Joaquin County Public Health Seirvices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, QA 95201 7e i <br /> il. <br /> INFO AMOUNT DUE <br /> /� AMOUNT R,�EMIT'TED CK l�}CASH RECEIVEDI9Y DATE PERhtIT'NO. <br /> . [Htl7/rItEV.rF1 6? rVl 1 C/O`U� f/` <br /> EH <br />