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• y <br /> APPLICATION FOR PEWT'1• <br /> SAN JOAQUIN COUNTY PUBLIC HSATTH SERVICES <br /> MMIJK)MU NTAL 88ALTH DIVISION <br /> 445 N SANT JOAQUINI, PHONE (209)468-3420 <br /> P O HOZ 2009, ftOCXIW, CA 95201 <br /> PB TT MIRES 1 MAR FROM DATE ISSUM <br /> (COMPlete in Triplicate) <br /> Application is hereby msde,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is glade in Compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health`Services. <br /> Job Address qC� \k1. \.N t Cott' Lot Sisr/Acreage <br /> Owners Nsnw Address I_ 3 ?;Z: 1��' Phon -q ca i <br /> Z PNpvT _TA� 111, Nm �So\ <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT 0 DESTRUCTION Out of Service hell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring won }g <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca Ois. of Well Excavation Ois. of Wed Casing H <br /> X Domestic/Private z Gravel Pad; ❑ Tracy Type of Ca ' Specifications <br /> t'1 Public Cl Other n Delta Depth of Grout Seal l-N 0 <br /> r Type of Greur� � <br /> I I Irrigation —Approx. Depth X Eastern Surface Seat Insuded by g' <br /> Row Work Done U Typo of Pump H.P. I State Work Oone <br /> Wed Destruction 9 Wag Dianwter ,_ ung Material i Depth - $� <br /> Doth Filler Material i Depth . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTION l I (No septic systarn permitted if public sewer is <br /> available within 200 feet.) <br /> brtallsdon wwa serve: Residence_ Conwrwrcial_ Other <br /> Nwnber of Coring units: Number of bedroorns <br /> Cheracsar of sad to a depth of 3 fest: Water table doth <br /> SEPTIC TANK. D Type/Mfg Capacity No. Compartrnants 44�� <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to Iwanat: Well Foundation Property Lim <br /> LEACHING LINE C1 No. A Length of nudes Total length/size <br /> FILTER BED O Distance to nearest: Wag Foundation Property Line <br /> SEEPAGE PITS 1 I Doth Sirs Number <br /> BUMPS LI Distance to nsarow. Won Foundation Property Lina <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 1 hoe pnparsd this aped A*m and that the work will be done in accordance with San Joaquin county ordinances.sten laws, and <br /> n n and rpdatiorw of tee San Joaquin County <br /> Items ov~or gtanws 4 spws sugnwtaurs canities the following: "I certify that in the performance of the work for which this p411 ol.is issued. 1 shall not <br /> 0 oioq any perw in such m/nrwr so to bstshrhw aubjsct to workman's compensation laws of Cadfomia."Contractors hiring or sub-contracting sipnatuw <br /> msrtffas the foMthwing:"1 artily twt in the pottormance of the work for which this permit is issued,i shad emptoY persons subject to workman's compwwo, <br /> Non Uwe of <br /> The east foe 1 wired inspections. Cornplpte drawing vsrss side. <br /> god Title: Date: <br /> FOR DEPARTMENT d1SE ONL <br /> Aon+Accoptedby Data 3 Ares <br /> Pit or Gram tno.detlon by oats Final Inspection by Ona <br /> Additional conwnant,. <br /> Applicant - Return all copies to: 'Ssa.souignin County Public Health Services <br /> Esviroarsntal Health Permit/services <br /> 443 N San Joaquin, P O Bos 2009. Stkn, CA 95201 <br /> FIN AMOUNT Out! AMOUNT ASAITTED CASH Rf INVIEO!Y t�/1TE PERspT'NO. �O <br /> Iwo <br /> . fit";sev.114.1*l -2�v-`I3 I33 <br /> IN <br />