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IL lar APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC FFEAr Th mCES c50(v <br /> ENVIRONMENTAL HEALTH DIVI I p <br /> 445 N SAN JOAQUIN, PHONE (209)468P�0 7{s + <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> ` _r.r i <br /> PERMIT EXPIRES 1 YEAR FROM DATE I$ II <br /> (Complete in Triplicate) 1 )r oi�y� <br /> Application is hereby site to Han Joaquin County for a permit to construct and/or'ins"fa <br /> sn <br /> apPlleation is de in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Han <br /> \x' Joaquin County Publlc Health 8ervlcee. <br /> ' Job Address 6 � (t/.} 2LC� Gly =4!--� Lot Size/Acreage <br /> Owrsi a Name Address 1, '57Y71 Lo O / Lb�- phorw <br /> XConhacta Address License No. _ Phone <br /> / TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Out of Service bell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ IEWER LINES DISPOSAL FLD. PROP_ LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS er <br /> INTENDED USE TYPE OF WELL PROBLEM AREA.; CONSTRUCTION SPECIFICATIONS p <br /> ❑ Industrial ❑ O --'— <br /> Open Bogan Ci Maniacs Dia. of Wen Excavation- Dia, of Wall Casing <br /> ❑ Domersht/Private ❑ GravelPack ❑ Tracy Type of Calling_l AL- Specifications �f <br /> Il Public Pn Omhers� fl Della Depth of Grout Sea! Type W Grout <br /> I I Inigalion _Approx. Depth I 1 Eastern Surface Seel Installed by <br /> Repan Work Done U Type of Pump H.P. _ Stan Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth <br /> Depth Filler Material Y Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i RE PAIR rA DOITION 1 ! DESTRUCTION I I (No "put system permilled it public sewer is <br /> available within 200 (eat.) <br /> Installation will serve: Realdencs _ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of 6011 to a Wpm of 3 feel: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Camper - not }, <br /> PKG- TREATMENT PLT. L1 P <br /> Distance to naeroc Well Foundation <br /> _ d <br /> LEACHING UNE ❑ No. b Length of INss _ Total le ix <br /> FILTER BED ❑ Distance to naarest: Well FoundationSAF+ <br /> ��ULTLIIC�H AJ <br /> N ( �C� — <br /> SEEPAGE PITS I I Depth Sim Num �r T"'• AL HFAI TH(iwl�eiP— <br /> SUMPS LI Deman to ~W 04t: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared Ihi1 sppkution and that the work will be done in accordance wwlh San Joaquin county ordinancoo, state Laws, and <br /> rube and reguleriors of the San Joaquin County <br /> Hay*owner or licensed Dam's sprotum comities the following: '9 comity that in the performance of the work for which this permit is issued, I shag not <br /> employ any person in such manner as to become Wbfect to workmen's compensation laws of California."COMFOCtnr' trscting ■Igralum <br /> ,Wifiss the following: "I comfy that in IM Performance of the work for which this putt is refund, I their rre eOns augecl to work rttpenef <br /> IioA awe of California." w L <br /> / The applicant must call for r equ d inspections. Complete drawing on reverse side. x O V -S u <br /> Signed If TitleDohr _ —w <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byOale Ana <br /> Ph a GrW1 IsspoSt n by Data Final Irupectlon by ✓ ^ Das lY/f <br /> Additions' ! Cir+S rT{!n / ��� B4/�.vm 5/car•r*� �+/ 5'r• -h7/d� S ;v <br /> A.a�A� iNCN o <br /> Ar,pl le t - Return all copier to: San Joaquin C /sty Public Health Services t✓.v �.p�.J. 4 ; �� <br /> Environmental Health Permit Servicea <br /> 445 N San Joaquin, P 0 Box 2000, Stkn, CA 95201 o/d, u.W /Irdt� d 5,FEE <br /> INFO AMOUNT DUE AMOUNT REMRTED SH RECEIVED 9y DATE PER IT-NO. <br /> Cir p 4aa <br /> ENt>.i.taEy ,,.b, v � vo � t3 306a <br /> EH 14x6 <br />