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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PRONE <br /> P O BOX 2009, STOCKTON, CA <br /> PERMIT RIPIRES I Y&U FROM ATR 08014D <br /> (Complete in Tripllcpm??"- 1� 2 <br /> Appliastiea is )merat7 asde to Sac Joaquin County for a pe:mlt to construct and/r6=���{M�} ilt{0/''vo[17 r6 a deecrlOaC. This <br /> I,Tlieatiea is ands in doat<illsnc+ vith San Joaquin Cc,nty Drell"nee No. 549 and : LAACAII ttLtions of Ran <br /> Jespuib eouaty Nblio Eealth barviceo, <br /> Job Addrea JC lr;, : -N ;fins n.; 4ry City`-�r er, Lot Slee/Aerew l.? -c,, <br /> i <br /> n I <br /> Owner's Name Add.... 1C - %i Vii' Phone <br /> I <br /> C entueter-`.VKiP4t�� pzlc�iry L, Address License No.Lai 4.F' Phone 1,1,°1P -f i <br /> TYPE VWILLIPUMP: NEW WELL 13 WELL REPLACEMENT F1 OESTRUCTION 0 Out o Service Well rr <br /> PUMP INSTALLATION Q SYSTEM REPAIR 0 OTHER Monitoring Well O <br /> )CIL "-p'I CyS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE _ _c",y <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENCEO VSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll industrlet O Open 0aitom ❑ Manures Dia, of RWvstr Eauvalion Cafirq <br /> ;.l pomeaie/Prhvets 0 Of" Pack d Tracy Type ol`Calsi,pSpecifications <br /> I'I Public I:I Other n Delta Depth o a Type of Grout �Qt C[fYIQrY-' <br /> I I Irfk}stlon _Approx. Depth I I Easter ursca Seal Installed by <br /> Repair Work Dano O Type of Pit 3 N.P. — State Work Done <br /> WAN 0411tfuction emetN Sealing Material a Depth <br /> Depth Filler Material a Depth <br /> P SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo sopna ayslam permittsd Y public <br /> available within 200 1eaL1 <br /> IMfaMtbn will serve: Residence__ Commercial_ Other <br /> Numbef of living units: _ Number of bedrooms <br /> Character of Boll to a depth of S foal: Water table depth <br /> SEPTIC TANK O Typo/Mfg Capacity No. Compartmants <br /> PKG!TREATMENT PLT,0 Method of Disposal <br /> Distance to nearer: Well Foundation Property Lie <br /> LEACHING LINE 0 No. & Length of Anes _.__ Total tengih//life <br /> FILTER DED ❑ Distance to neoreu: Well Foundation <br /> SEEPAGE PITS It Depth Number <br /> SUMPS to netiont: Well Foundation Property Lina <br /> S O <br /> I hereby-ortlfy till I hove prepared this aDNicstlon ani that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and rapAailone of the San Joaquin County <br /> Hama pwW or HCinsed agent's Mgnsturs certifies the 100*wing: "I certify that In the performance of the work for which this permit Its issued, 1 shall not <br /> employ any person In such mariner as to become subitot to workman's compensation laws of Calilornlo."Contractor's hiring of subbcofnrscting siontlure <br /> oertllias the folowfng: "1 coMly,that In too psfiorm"of the work for which this permit Is Issued. I$hall employ persona subject to workman's C*mpenss <br /> Son awe of California." <br /> The took I tall for al fequkod 1 apectbns. Complete drawing on reverse old*. <br /> Title, f i7 cs,0e - ��_C. 1 ry Oats: <br /> FOR DEPARTMENT USE ONLY �/I I <br /> Apinkatlon ACCepled by Oats I^-23 Area ` :X7 .�`-' <br /> PN or Grout Inspection by Data Final Inspection by Date <br /> Addhlone Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Sovironmental Health Permit/Services <br /> 445 N Ban Joaquin, P O Sox 2009, Stko, CA 95201 <br /> Fee <br /> INFO AMOUNT DUE AMOUNT NEMITTED CASH RECEIV�EDD ly DATE i c� PGEAMMIT'NO, <br /> tNe17 17, <br /> 14-Mterv.rr$u V �U U �� 1z L <br /> !N la. <br />