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F _ <br /> �f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH bERVICES <br /> `I ENVIRONMENTAL IEALTH DIVISION <br /> P 0 BOT 2009, S7-WKTON, CA 95201 <br /> (209) 468-3447 <br /> T REIT EXPIRES 1 YEAR PROI1 UAIR ISSUED <br /> (Complete in Triplicate) <br /> Application to hereby nada to Ban Joaquin County for a permit to conotruct and/or install the work herein described. This <br /> application Is made In cc4llance with Ban Joaquin County Ordinance Ile. 549 and 1062 and the Rules and Regulations of San <br /> Joaquin County Public Health Berviets. <br /> �3 Covt�'�t'r� [�� �?( ty� � o� <br /> .fob Address ) ti.. _ City Lot wise/Acreage <br /> i <br /> t Owner's Nama l3 j to t j Addles' `gkLko Cx c(w Phon <br /> CentractorY&,-f/uA? _ Address -e1b C /'�y�"rpt :S 'License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT f_1 DESTRUCTION XOut of Service deli O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ monitoring Well <br /> _ DISTANCE TO NZAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE <br /> i E FOUNDATION AGRICULTURE WELL OTHER WELL—PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f.1 IndWtrq -� ❑Open Bottom O Maniacs Dis, of Well Excavation Dia.of Well Casing <br /> t fJ DBmQtit7Prkaia Cl Grovel Pack l7 Tracy Type of Casing Specifications <br /> D Pelbfie I:1 OIh" ❑Delta Depth of Grout Seal Type of Gtoul <br /> s l M Irrigation Apptox. Depth 0��Eastern Surface Seal Installed by <br /> [ , Repair Work Done U Type m <br /> of bump MA H.P. StaraW—f,DOM* <br /> I Wer Destruction OR Well Olameter tt-ff,�-» Sealing Mterlal i Depth fie. , <br /> Cfpth 30 'R � Filler fhterial i 1)c�t+. to a+ -12' s c�N <br /> 5 L <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADOITION 0 DEST CTION G INo tepric system permitted it public Fewer Is <br /> available within 200 test.) <br /> r 5 �_tlmts11atl0n will serve: R*sidencs_ Comrnlrelat OthF- <br /> Number of Rving units: NumWr of ttdr0an a �� <br /> Chlriet*r of BOM to a depth of S feet: Watu table depth <br /> SEPTIC TANK Q Types/Mfg Capacity No.Compartments <br /> PKG. TREATMENT PLT.IJ Method of Disposal <br /> r Distinct to nearest: war ndation PropanV Line <br /> r <br /> t 4 LEACH-NO LINE 0 No.B Length of Tinea Total length/site <br /> FILTER BED n Distance to nearest: Wan Found Ion Property Line - <br /> .. IY+ <br /> I SEEPAGE PITS I I Depth S Number <br /> F SUMPS Lt Diapineo 10 naarest: eK Foundation. Property Line <br /> r <br /> *' DISPOSAL PONOS ❑ <br /> I hersby eanify that I have prepared Phil application and that the work will he done In accoodance with San Joaquin county ordinances,811116 taws,and <br /> rules Ind regulations of Ihr,Den Josquin County <br /> Home owner or licensed P?ent'i signature anifics the lolfowing:"I cenity that In the performance of the work lot which this pefn4t if Wu*d,I shell not <br /> employ any ponOR In SV.A nwnner as to become lubOv to workmen's compensation laws Of California."Contractor's hiring Or sub•conirsellno aigneture <br /> i..� e11niflss the f <br /> s l r OltetvUg:"I certify that in IM performance of the work for which this permit is Issued,I Shall employ peruse sublet to workman's eempenu• <br /> tion laws of Clrfornfs." <br /> The eppw.snt must cal lot ON required 1tupvcitane,Compfote drawing on ravers*side. t_ <br /> h f # Slgnad Title: �rlll/? Ste• — <br /> Hate: z <br /> z � i <br /> try FOR DEPARTMENT UDt ONLY <br /> Apolkaftri.Aeeiptedby Date d5'Q Area <br /> Pit or prom Inspection by .r pati Flnal inspection by Date <br /> t i Applieaat - 1lBtur4 au coplll tel But JOAgUIN COUNTY PUBLIC HEALTH SERVICES <br /> k "f ENVIACUENTAL HEALTH DIYIBIOH PXRMIT/uRVICES <br /> i; 445 le $Ail JOAQUIN, P O BOK aoog, CTUCKTON, CA 00101 <br /> CK 8 <br /> it 4 i i tNfC AMOUNT OUR AMCUNT RIM01E0 CASH ECEIVED By DATE PERMIT NO, <br /> s, <br /> . r' 577l IR[V.ver, <br /> Y <br /> d`� <br />