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z. APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> N' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ;.: P U BOX 2009, STOCKTON, CA 952.01 <br /> ;R, <br /> `: PEfUSIT E$P�$ ISO= <br /> (Complete in Triplicate) <br /> - - _ Aypllcatlon 1■ herby mde•to Baa Jo+qulo County tvr a permit to construes and/or install the work hsreia described. This <br /> application 1. made In compliance vith Baa Joaquin County Ordinance No. 549 and 1862 am the Rule and Roculatlons of San <br /> Joequla County Public health Dervices. . <br /> JO Addrrae 9 t (O4, Fe 4 C oT/u /Jcr! City dey,C& C Ise Lot eiSO/Ac reaEe <br /> Owrw'i Nome /5 SI ar v rY i/4 ,_,,, Address <br /> .5 - <br /> �+; Cn:urtcta rJ�� 4 Toni _ Address 1-7 ej V —_License No.yrt! Phony <br /> YPEOF W£L1/PUMP: NEW WELL O W LL REPLACEMENT fl DESTRUCTION Cl Dut. of rr e■ 12-. <br /> PUMP INSTALLATION fa SYSTEM REPAIR ❑ OTHER O ..110otsorlK �,''❑ <br /> DISTANCE 70 N:AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP s INE <br /> 6 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I k° C1 Industrial O Open Bottom 0 Manteca Dia.of Well Ereevetion Dia.of W■M Caeh+g <br /> C.1 Domes+klPrhrete Cl Gravel Pack 0 Tracy Type of Cooing,„ $pedfkelions �\ <br /> ?; I'1 Publk <br /> fl Other fl Dells Depth of Grout Seat Type Of Grout \ <br /> E I I Irrlpelion Appos, Depth I I tEaetern - Surlau Seal Instilled by <br /> - 'Repair Wak done U Type of Pump H.P. - State Work Done <br /> 8ea11 <br /> We11 Owtruction O Well DWneter <br /> Material A Depth <br /> Davies tiller Natarlal A depth <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION'I I REPAIRrADDITION kI DESIRUCTtON I I {No eeptic system pHmilted If public saw■r is, <br /> avarlabN within 20C fMt I <br /> InstaKIRIOn will 941": ,Raklence L Commercial^ Other m _ <br /> .,, . <br /> Number of living Units:.L,._ Humber of bttdroome <br /> "tf <br /> WSW table depth <br /> Chmaeter of soM to a daplh til i feet: <br /> t Capatity .No.CoeNwIrn■nt■ <br /> + P1� <br /> SEPTIC TANK ❑ -T"/Mfg , <br /> a. "hod o!Dkposal <br /> R, <br /> PKG.TREATMENT,PLT.L7 <br /> r Distance to nearest:_ WellFoundation Property Lot■ a <br /> r? of lines LINE '0' No.8 Length Total len th/s4o <br /> FILTER BED 0 Dlslanca to namest: Wail Foundation Prop"Line <br /> 4 <br /> YV l I Depth ! r — Ssre7NumberSEEPAGE PITS ` <br /> SUf,RPB- An Distance.to naerast. . Well GO Foundation Properly Llne <br /> E .DISPOSAL PONDS Q r <br /> t" 4I.hereby certify that I have prepared this spplrcation and that the work will be done in accordenee with Son Joequfn county Ordinances steq iews.ttrt� <br /> ,.rulew and rpu4tiorte of the,San Joaquin County <br /> ;FIOrt'M owner or ocw*w agent's signature oartifies the lokowing:"I cattily that In the performance of the work for which this paltnN is hinued,11 MtiE riot <br /> .employ any psreon In.such Manner as to became aubit.l to workman's compensation laws of Cellforma.','ConlfeeloeS hiring W artba.,frf"alpJlalure' <br /> ""Mse the f0scrWing:;'I certify that in the performance o1 the work for which this perlttll le issued.I shall■mploy p■n9ne wb�eeT to yaorkmert a et>e+tprnee., <br /> a tkx+WWW_f California: <br /> T1w applicant C"fcw all required inepedions. Complete drawing on reverse side. <br /> 'f Signed)( _ Tills: Das: <br /> +' <br /> FOlt ARTM USE ONLY <br /> Apphution Accepted Ey 0810 A+ <br /> PH or Grout Inspection by _ Deli Final Inspection ti <br /> Addhionsl Cornmsnta: <br /> { <br /> Applicant - Return all copied to. Dan Joequ3, County Public Health Bervieee <br /> Environmental Health Terleit/Servtor■ <br /> r �• 446 R BAA Joaquln, V Boa 7010, Btka, CA 961101 -- <br /> F11AlAOtJNT OUE AMOUNT REMIT'1'tb R!CltVlD Y 6 TE - -'►EnIrfIT•MO.'- /�/i <br /> Vt 1124 l."'. <br /> •_, TSL. <br /> r � ' <br /> ' . Y- r, - - �- , ?w ✓, ^' r�. �: � � r � � � is <br />