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<br /> APPLICATION 1
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIECMUMTAL .HEALTH DIVISION
<br /> 445 N SAN JOAQUIN, PHONE (209)458-3420
<br /> P 0 BOX 2009, STOCETON, CA 95201 '
<br /> PEMIT ESPZRBS 1 YEAR—FROM_VATFs ISSUER
<br /> (Complete in Triplicate)
<br /> Application Is hereby made to tam Joaquin County for a permit to eonstrQ� and/or install the vort beret described.-;Thlr,.�
<br /> application is made in compliance vith San Joaquin County Ordinance Ito. 549 ar•: 1B62 and the Rules and Regulations.of Sen -
<br /> Joaquin County PublIt Health Serricea. - -
<br /> Jor - •
<br /> Job Address Lot Sine/Acree;ge
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<br /> Ow:Ier's Name r f `54 Address.!A� Phone
<br /> l• � �'1' �,� e
<br /> Con1factor Atldres l+ License Nr> � ¢ Pho 1
<br /> TYPE OF WELL/PUMP:it „NEW WELL,❑ WELL REPLACEMFNT h DESTRUCTION G Out of.,Serrice.tlell
<br /> i PUMP INSTALLATION G SYSTEM hEPAIR ❑ tJ7HER:C1 ltmtitoriHR iJeli i d`
<br /> DISTANCE 70 NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD:..._..� PROP'LINE E
<br /> x
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
<br /> INTENDED USETYPE OF WELL PROBLEM AREA t 01:'$TAIICTION SPECIFICATIONS
<br /> G in4Yatrial .,C]Open Bottom C3Manteca Dia.at Well Excavation Dia.of WeM Citing
<br /> Cl Oamastic/Privala G Gravel Pack ❑Tracy Type of Casing__ _ 5peedlcatbns
<br /> 1'1 P Ibha Cl Other n Delta Dep h oLG+aut Seal type a!Grotrt`
<br /> t i,irtiucion Approx. Depth I I Eastern Surface Soul Installed by "
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<br /> t
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<br /> H. State SlatelNark Dont_
<br /> Repair Work Done L7 ,Type of Pump
<br /> Sal
<br /> L' }th >_e
<br /> $tali !tater .F .
<br /> .,;1VeN DnWctiatt i7, Well Diameter,
<br /> Depth` > tiller flat -ial'R Depth i-s"- rxt.
<br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I AEPAIR/ADDITION DESTRUCTION 1 114• toptic system permtned it ptrpHc Soret
<br /> yf, available within 2W feat} vt r } s
<br /> Instillation exit serve:, nce Reside „ -Commercla! "Other",
<br /> Number of living units: NumberonAf b*e�dro,ar,s `3 La
<br /> Chaiictar of 0011 to a depth of.3'1ee1: l �^ Water table deptl4
<br /> SEPTIC TANK t54� ❑ Type/Mfg,�Bi _Capacity No 61 m1 1111 �v
<br /> PKG TREATMENT PLT.❑ Method of Dnpos�f
<br /> Distinct to nearest Woll Foundetron Prr a',t/Line r E �' iit'
<br /> LEACHING'INE J� No.8 Length of Ilnes _[��p Tala1 1armh/s sa`
<br /> FILTER BED' 0 Dilitah"to newest Well (?r ',FoundAtwn Proparty'Lhfe
<br /> SEEPAGE PITS I I 'Diplh — _ Sire Number
<br /> SUMPS a Distinct to poetess WA' Foundation' 10
<br /> s '-Property-Liner
<br /> DISPOSAL PONDS 0':
<br /> I hereby certify that I have prepared this application and that the work Will be done,In accordance with San JaWuin COtinty wdMancea ttab!asci
<br /> rules and rogulaiions of the San Joaquin County.
<br /> Home owner or Ii.ensed agent's signature certifies the following "I cortHy that in the-pirformance,of the worlt for v.kdch that per"A l•4WW,.,t-,ehtM y
<br /> smploy,sny person in such manner as to br coma subject to workmen's compnrtaerlon Iowa of California.'Contractor'a hiring or sub.comrecting t+lgnefure�k `
<br /> certifies the following:"I certify that in the performance of the work for which this permit Is Issued,I shall employ,persons subject td'ivorkman a compotNN
<br /> ;ion laws of California:',
<br /> The applicant must tell�w alk �- it in tions.'Compi drawmg'on revers
<br /> Sigr»d - CEJ Ti L.. Q �.t.
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<br /> F'R.DEPARTMENT USE ONLY 4s �Yt "errs
<br /> Applrtibn Aeeaptad by
<br /> Date
<br /> Pit or shout Inspeeticn by Date final inspection b Det✓ ,.r yN
<br /> Addkicnel Comments:
<br /> Applicant - Returr 011'copies tW; San Joaquin County Public Health Services r'� t
<br /> , $oviron"ntal Health Permli/Servlusm
<br /> - - „-445,N Saa,Joao-iln, P O Box 9009 Stka,,CA 95201
<br /> J:
<br /> afC AMOUNT bVE _AMOVNT hEMITT£D Imelvect aV;:i ,ATE :iEI111frT'NO a •kiYrt- 421,;,,•+si'.
<br /> . fN ri•711J;ry ,/�t, " t I / - I ;1,1�� V, _ r 'Tr :.� `s ' '..
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