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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV IROM9NTAL IIEALTII DIVISION <br /> 445 N SAN JOA.QUIN, PSONE (209)468-3420 <br /> P 0 BOX 2049, STOCKTON , CA 95201 <br /> PERMIT EXPTRES I YEAR FROM DATE ISSUED <br /> (Complete in 'rripiicare) <br /> Application la hereoy mode to Sam Joaquin County for a permit to construct and/or install the vork herein described. <br /> agplicatiab it made in cos>pliance with Sou Joaquin County Ordinance No. 5119 and 1862 and the Rules sad Regulations of <br /> Joaquin County Public H <br /> ea <br /> lth Services. <br /> Job Address <br /> 22.2 City `� � tat Sise/ACreeae40 42C4A <br /> Owner'a Narita P"e«Cilt� C 1,N t Addrass 400 e . {Acu&,t S�. F1 DDC Phone �54L-6.91.r <br /> a.,Ac- , = 9 --40 <br /> Contractor Address License No. Phone <br /> TYPE OF WELLlPUMP• NEW WELL = WELL REPLACEMENT i,, DESTRUCTION C Out' df Set'Yit;e Well <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑. OTHER C Monitoring Well DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO. E <br /> PROP. LIN <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br />' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial ❑ Own Bottom 0 Manteca Oia. of Well Excavation - t S Dia. of Well Casing <br /> (1 Domesncf Private t /61avel Pack ` _ L7 Traci Type of Casing_ �- ' SCS 4 0 Specifications <br />' I'1 Pubic 1"7 Other bOCGK i� DNIa Deotn of Grout-Seal 22 .l[X Type of Grout r�_ 1 <br /> i I irrgpotion _Approx. Depth i I Eastern Sariacs Saul Instated by IQtr`�'1flwta <br /> Repair Work Done L] Type of Pump H.P. State wort Done <br /> Well Destruction ❑ W" Diameter %1AdA#S Sealing Material i Depth <br />' Death d-1 LAA'- filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION!.� REPAIR IADOIT1014 I , DESTRUCTION I lNo septic system owmnted d public sr Not , <br /> ' available within 200 leat.l <br /> 1Wnzlefistion ,anll serve: Residence - Commercial Other . <br /> umber of Irving units: Number at bearoorm <br /> Character of sod to a death of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type1M1g Capacity No. Contnartments � <br />' PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to newesti Well Founastion Property Lina <br /> A U( <br /> LEACHING LINE ❑ No. 6 Length of lines Total lenginisixe - <br /> FILTER BED n Distance to neaeast: Well Foundation Property Line <br /> SEEPAGE PITS I I_ Depth Sirs `Number <br /> SUMPS LI Distance to nearest: WSW• Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that I have prepared this application and that lne work will be acne in accordance with San Joaauin county ordinancetr Mete law <br /> rules and regulations of Ins San Joaquin Country <br /> Home owner or licensed agent's signature Certifies the following: "I Cartity that in the performance at the wort for which this permit n issued. I sh <br /> employ any person in.such marinst as to became aubNct to Workmen's comoensalion laws of California.' Contractor's hiring or lut)CantraCling sig <br /> canities the topow,ing: "1 ceitity that in the performance of the work for which this pernut is issued. I&heti employ persons subject to workman's cam <br /> coon tows of California.- <br /> The apple n must call for all reourree inspections. Complete drawing on r rse side. <br /> Signed x Title. d i e L� � °a„ej Osie: 4 f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r °� Ares <br /> Pel or Grout inspection by Date Final inspection by Data <br /> dditlonal Comments:!' 6 . 15 <br /> Appiicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services J <br /> 443 N Spa Joaquin. P O Box 2009, StAn. CA 93201 <br /> FEE AMWNT DUF AMOUNT REMtlTTE13 CK a f RECEIVED 0r GATE fE11M1T NO. `C <br /> INFO <br /> 9 CASH P <br /> �t12attiew.%iass f�lA�/ � �f 4 r- <br /> ta.as / /�V <br />