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(� 1 APPLICATION SR # - <br /> . s�/y(4q m S _` .+� ice•- - }� <br /> G>l �,y� fib?F' JOAQUIN COUNTY PUBLIC HEALTH SE $JW# <br /> () ENVIRONMENTAL HEALTH 101 ���# <br /> 445 N SAN JOAQUIN,PHONE(209)469-3 2 <br /> P O BOX 388,STOCKTON,CA 95201-03 <br /> PERMIT IR l Y R D <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> !J y S2zo 5-r �45 <br /> Z 7173 ri5y� n �� <br /> /Acreage <br /> Job Address Cit,CotSize <br /> Atltlres733p� � � � Gq <br /> Owner's Name c/9WaY M oneZ <br /> zo <br /> `y'522N a12_9911 Phone -3&/^ <br /> Contractor �C '� Address���Z�• `4�//� '�"'�)�License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑-'Out Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing_ Specifications <br /> 1'I Public 11 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Materlal a Depth <br /> Depth _ Tiller Material i Depth <br /> TYPE OF EPTIC WORK. NjEW 14STALLATION I I REPAIR/ADpITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> PAYAII'E '"ithin 20o feet.)nsullation wt I serve: esrdanccommercial_ Other <br /> Number of living units: _ Number of bedrooms RECEIVED <br /> Character of sell to a depth of 3 feet: W 0 99%r table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity Cb��Pamrmnts <br /> PKG. TREATMENT PLT. ❑ SA:S J � 0866 Disposal <br /> Distance to nearest: Well Foundation PUBLIC HE L AtWVIS10N <br /> ENViR01�� <br /> LEACHING LINE ❑ No. B Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepare 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 comity that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California.- Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's componas <br /> tion laws of California." <br /> The applicant must ceR for all r wired inn tions/Complete.drawing on reverse side. <br /> Signed xk4:2� �1:LJK�(.Li� Title: 422 Y1 Z 22 <br /> 7�?ZA",.E� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � Date Area Z I� <br /> Pit or Grout Inspection by Date Final Inspection byZAaiZe:241k-z1/ Dato­Ef�f � <br /> Additional Comments: ' 7 — cJo GQP�,O pU&09 V- - raa.cr .>,.. a��-ch Al /o.a <br /> 2 . '7,>dusonlfJ- <br /> Applicant - Return all popies to: County Se" pti.e �^d)•L�NP�R....s_-ai '{7 was <br /> EnvGonmental Health Permil/Services ,p,¢.-C 1 / <br /> 445 N.San Joaquin,P.O.B 88,Stockton,CA 95201-03Jf8 / <br /> NFEE PO AMOUNT DUE AMOUNT REMITTED K - ECEIVED BY 6 `l DATE P�E7RnMI6NO. �TiQ M <br /> 904 1 EH 1a-1 IREV rrs s! Z3 . . b, 3 % <br />