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APPLICATION FOR PERHIT,",� <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 PA <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MA C����� <br /> (Complete in Triplicate) SA26 <br /> N,/ 19 3 <br /> Application is hereby ride to on Joaquin County for n permit to construct and/or install PuBtIc IVC <br /> th N eil�p� �hie <br /> application to rade in compSan <br /> with Elan Joaquin County Ordinance No. 549 and 1862 and the Rules an b n <br /> Joaquin County Public Health Services. L/ <br /> fon+ <br /> Job Address <br /> LO�Cit�yH sLot Size/Acreage <br /> IJ -aOwner's Namo ^ rrn Address / AY!Phone <br /> LAddress �/s � License No �Contracto(Sd)l 10rahe#, M; a � 0Phone <br /> Phone?0J T 'L� <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT fl DESTRUCTION Cl Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [l Industrial O Open Bottom O Manteca Die. of Well Excavation Dia. of Well Casing - /A <br /> (1 nnmestic/Private 1-1 Grovel Pack L I-1 Trr•ry Tvre of rami-,q pvU`j �+ Cr.wr Itlr nli..nr �Q <br /> I I M.1,11r Il•111jirhr Arm,..*I...r 1 I ibNle Iryr111 rrl Ih r.r.1 '��+1 1'�✓+�s'�� I1nr r.l 11�,�n1✓�i►Wi►r <br /> 1 IYntfrllnn 8Lt1Apjslox. lle/Nh 7 I I kaileul bwtacr eul h1.IrIw./ 4i sdi�a�_� _ <br /> Repair Work Done LJ Typo of Pump A/* H.P. N� tate Work ne <br /> Woo Destruction O Well Diameter Z rncA Stealing Material 6 Depth �p 30,E <br /> Depth �/d" - Tiller Materlal b Depth 4 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will servo: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soll to a depth of 3 foot: Water table depth <br /> SEPTIC TANK O Typo/Mf Capacity No. Compartments <br /> PKG. TREATMENT PLT. Method of Disposal <br /> Distance to nearest: Well Foundation Property Lino n <br /> LEACHING LINE Ll No. A Length of lines Total length/size_ <br /> FILTER BED oundstion Property Line l <br /> SEEPAGE PITS I I Depth Sire <br /> SUMPS rest: Well Foundation Property Lino <br /> R NDS O <br /> 1 hereby certify that 1 hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin County <br /> Homo owner or licensed agent's signature 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the fol$owing: "I cortify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's componsa- <br /> tion laws of Califo►nic." <br /> The a a call for cel roqu' in c' drawing on reverse side. <br /> Sig Title: __ �0 60 y !S J Date: <br /> '/��'-y-�JALFOR DEPARTMENT USE ONLY �j 5 %S. <br /> App on Accepted by ' ' 1 Date �� 'v `� Area <br /> Pit or Grout Inspection by/+,mac Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> • EN 11 N 11tEV.ria31 �� ]�`7 V <br /> 1. <br /> ( ✓/ <br /> EH 14.27 v 1 1 J I v <br />