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0 APPLICATION FOR PERMIT • ptislyza <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468- 342U MAY 2 5 1995 <br /> PERMIT ERPIRES T YEAR FROM DATE TS41IFiT ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMff/SERVICES <br /> Application Is hereby made to Sao Joaquin County ror a permit to construct and/or install the work herein RVICEbed. This <br /> application is made 1n ec�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and in describe . San <br /> Joaquin County Public 'Health Services. <br /> PN 1&3- 2-3- 41 <br /> Job Address 45 /L, C'-ARLEa w4y <br /> ..,,11 CO. —�, n Gly S7YlGY7Z4y Lot Siu/acreage <br /> Owner's Name Wa H/ /N It S tt��Address LO iA 12W (.a'r$ /�Lrc�03 CSA, ft23 phon I Yds.-G 7Cs,. <br /> Contractor AddressR' ikx2231 J&ocle Ces.�J �IenseNo&Z4k7 Phorfe 612-5 SS <br /> TYPE OF WELL/PUMP: NEW WELL CZ WELL REPLACEMENT O DESTRUCTION O Out or Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER D Monitoring Well A <br /> DISTANCE TO NEAREST: SEPTIC TANK .SCO SEWER LINES _100' DISPOSAL FLO.,40� PROP. LINE In <br /> FOUNDATION —1--T AGRICULTURE WELL &e_-4 OTHER WELL PITS/SUMPS Zdr,-, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom O Manteca Die. of Well ExcavationDia. of Well Casing 2 <br /> V Domastic/Private • JiLGravel Pack O Tracy Type of Casing -Pic <br /> r Specifications Soh 40 <br /> O Public f:1 Other 1 <br /> O galla Depth of Grout Seals: UJ __ Type of Grout C IMT <br /> CI Imgalion 4,�J_Approx. Depth O Eastern Surface Seal Installed by_ 'IT1-atC4cr <br /> Raoeir Wort Done 0 Type of Pump H.P. . State Work Dona _ <br /> Wall Destruction O Well Diameter Sealing Material a Depth <br /> Depth Filler Material a Depth _ <br /> TYPE OF SEPTIC WOAK: NEW INSTALLATION 0 REPAIR/AbDIT10N L1 DESTRUCTIONP<No septic system permitted it public sewer is <br /> Installation will sent. Residence _ Commercial_ Other available within 200 feet.) <br /> .Number of living. nits; _ Number of bedrooms <br /> Chersclaf of soil'to a Ih of J leeh _Water table Depth <br /> SEPTIC TANK O Type Capacity___,.` No. Compartments <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> Distance to nearest all o n Property Lina <br /> LEACHING LINE O No. 8 L in of lines _ Total length <br /> FILTER BED O D ice to nearest: Well Foundation Property Line <br /> SEEPAGE PITS - 11 Depth Sire __ Number <br /> SUMPS CI Distance to nearest: Well Foundation Progeny Line <br /> DISPOSAL PONDS O <br /> 1 hereby candy that I have 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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cenify that in the performance of the work lot 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 California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa. <br /> lion laws of California." <br /> The applicant II r all to ui ed inspections. Complete drawing <br /> on reverse side. <br /> Signed Title:(NW�r�Tau� �,Ar <br /> oats: / rl/t/Z4 <br /> OR PARTMENT USE ONLY <br /> Application Ac pled by <br /> Dalat <br /> Area <br /> a <br /> Pit or Grout Inspection by Date Final Impaction by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONUENTAL HEALTH DIVISION PERU IT/SEBY ICES <br /> 445 N SAN JOAQUIN. P 0 BOK 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INfO CASH RECENED av <br /> i" t i.Ir -- �DAACTE V PERMIT NO. <br /> t.M wI VU <br />