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l , APPLICATION `^; <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCSTON, CA 95201 <br /> EMIT EXPIRES I Y.�n' M DATE ISSUED <br /> (Complete in Triplicate) <br /> A,yplicstioa is bereby zs".to Ban Joaquin County for a Permit to construct &War install the vork beret* described. This <br /> application is ante in oayliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 ��`''�''j(� <br /> Job Address I yQ If ` O—j6 �1� City-.T 4.frrE49! flJ '- Lot Size/Acreage <br /> Owner's Narita T l �S�Aress yG-• Phone <br /> Contractor � ;� t Address • '` r � License No. r— <br /> TYPE OF WELL/PUMP: NEW WELL O WELL AEPLACEMENT ❑ DESTRUCTION F1 Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring well d <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 /> C1 Industrial O Open Bottorn O Manteca Ois. of Wei Excavation Oia. of Well CasLL Casing <br /> t1 Domestic/Private O Gravel Pack O Tracy Type of Coring �� Specification- ZA �. <br /> 1'1 Pubiie n Other fl Delta Depth of Grout Seat Type of Grout AJ Sa <br /> I I Irrigation —Approx. Depth I I Eastern Surface S*W Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Oone <br /> Well Destruction 6f Well D+arneter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I INo optic system permitted if pubic saws is <br /> sysileWs within 200 fest.! <br /> htaainion Other <br /> will serve: Residence— Commercial_ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 tea: Wates table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Con"Mmunam <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACH" LINE Cl No. 8 Length of linea Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property LIM <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to neaest: Well Foundation Property Line <br /> WSPO"L PONDS O <br /> I hereby cattily that 1 have prepared Mit application and that the work will be done in accordance with San Joaquin county ordinances, stat taws, and <br /> rules and reguistione of the San Joaquin County <br /> Mona owner or ice-wed agent's signature eertifisa the following: "1 certify that in the Performance of the work for which this permit is opued,1 shat tnot <br /> employ my Peso-in such m w as to become subject to workmen's Compensation Maws of Caiforma.,'Contactors hiring or sub•oo-tract+ng signature <br /> *Rift*Me follmirtg:"1 certify that in the parformancs of the work for which this permit is issued,I shelf employ persons st,bjea to workmen's compertss- <br /> Nen laws of QWomis." <br /> The AP~rust*Call f ale"KP*W inspections. Complete drawing on averse side. <br /> f <br /> Siwfed Trus: A0WNQ.Q Dat: <br /> Fze�: OR DEPARTMENT USE ONLY <br /> Application Accepted byDat q ? 13 <br /> Ph or orout Inspection by Dat. —/3 93 FkW inspection by Dste <br /> Addttioni l cornrn.-ts: Q" tf"L/ <br /> Applicant - Return all copies to: Sea. Joaquin County Public Health Services h Q <br /> RATIroaaeetal Health Peralt/Services ,v! <br /> 443 N San Joaquin, P O Box 2009, Stkn, CA 952 <br /> INFOIN CASH DUE <br /> A1dOUNT AEMtTTED CK 8 <br /> CASH RECEIVED By DATE PEAMIT•NO. <br /> . EM 13-74IftV.tixso 6 1 1 T-WO -3 j 3�. 961/ <br /> EN 14.20 �J <br />