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S7 <br /> .,► APPLICA710h FOP PERMIT �I1 � <br /> SAN JOAQUIN COU2�I'Y PUBLIC SHALT 5�.�VICgS <br /> ENVIRONYSNTAL HEALTH DIVI + <br /> 445 N SAN JOAQUIN , PHONE (209) 6 4 0 <br /> P O BOX 2009 , STOCKTON , CA W ft <br /> �r -zuiTR R <br /> (Complete in Triplicate <br /> Application is hereby lade 1Jo Sat Joaquin County fol a perch to construct and/or install the work herein described This <br /> application is made in cor-pllance vith San Joaquin County Ordins.nce ho 549 a-nd 1$62 and the Rules " Regulations of San <br /> Joaquin County public health Services <br /> Job Address -2� r7 City Lot Sire/Acreage <br /> Owner s Name lh+P1/r^U.� V-SA N'pjj jt Add,.,s12-qrD_Ccie± Kis R-0-y-4-Aki� Sc.,& R9 -4q-*LPnone �61 -9 <br /> r r ( p <br /> Contractor S.,Ir al. S 14ddress icenst: No S"7 Phbne 7'�S <br /> TYPE OF WELL/PUMP NEW WELL 8' WELL REPLACEMENT n DESTRUCTION 0 Out of Service )well C1 <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ %onitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES d P-7- DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia of Wall Eacavarron Du of Well Casing <br /> a �. <br /> Domestic/Prtrala C1 Gravel Pack 0 Tracy Type o' Casml; 0 ilC._. 5Decsfrcatrons e) <br /> I I Public rl Other f'1 Dolls Depth or Grout Seal D- 2. ; Type of Grout <br /> I I Irrrpalion _ Approx Depth I I Eastern Surface Saul Installed by SSS <br /> Aaoarr Work Done U Type of Pump H P State Work Done I1rrl1„AjTa A <br /> Wolf Destruction ❑ Wall Diameter fiesilin8 lisateri&l ✓t Depth <br /> Depth Tiller lsaterial i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if pubIr[ "war is <br /> available within 200 legit } <br /> instaustion will serve Rrardence ____ Commercial___,_ Other <br /> Number of kving units Number of Mdroomtf� <br /> Character of sol+ to a depth of 3 Iret P��'4 Ggsalh <br /> F <br /> SEPTIC TANK ❑ TYP41mig Capacity 4�F r4onu <br /> PKG TREATMENT PLT ❑ APRMeth> `o sal <br /> Distance to rwarest Well Foundation 4L.rZ. f _ <br /> USI �I U� l n <br /> LEACHING LINE 0 No b Length of lines ~'r�'r/o[tdl�o4 ru We <br /> FILTER BED ❑ Distanca to nasrest Wet' FountisUon Propertyy Ltne <br /> SEEPAGE PITS fl Daoth Sue Number <br /> SUMPS LI DtstaracA to nearest Well Foundation Property Lima <br /> DISPOSAL PONDS O <br /> I hereby certify thal I have prepareC this applrcatron and that the work will be done in accorclance with San Joaousn county ordinances state taws and <br /> rules and ►ayulalrorw of the Son Joeousn County <br /> Horne owtaer Or kona+d event i srgnsiura (tertows. the loilomng I comity that in the performance of the work for which this perms it issued I Ghali not <br /> 41mP+0y any patron in auch manner at to bocorno subheci to workman% cornpen"tion laws of CAliforrua Contractor a hemp or auaContra cling tugnaturs <br /> -mllseS the loaowing I comity that in the periormance of the work for which this p 4rrril is issuoti 1 &hull employ persons subhact to workman s com;>*nsa <br /> iron JAWS of Cafrlorrra <br /> TM NPOd"ni mut' Call for all requRrQ rrisvoctiont Complete orawrng on reverse p � <br /> s-de? u <br /> SnTitle SS c., C P_ n Dale <br /> Y <br /> FOR DEPARTMENT USE ONLY 35 f <br /> Apo2Ka[l4n Accaglad by Pat• Area <br /> Ph or Grout inspection by Date Final inspection by Data <br /> �Addnlonar Convrrnu <br /> a Applicant - Heturr all copies tc San ,loapuin Coun-- public Ilealti, Seralcee <br /> Snalroamental Health Pe-nit/Seroicee „ r itis <br /> 445 Is San Joaquin, P O Box 200P Stkn, CA A5201— <br /> IkFO AMOUNT DUE AMOUNT REMITTED CK CLASH RECEIVED my DATE PERMn Np <br /> E�,�x tate i..ti V 1 Z51' SOIL' }��1� j4z� ! ZG`!1-1__ <br />