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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appllutio. fa hereby .ode t0 Sm Joayul. County for a pe t to cone tract an /or dIru ll the work herein described. TTS. <br /> -Mlicatioe I. PSC. Sn cevyllana with Sen Jo.9oin County Ordinance No. 549 and 1842 and the Rule. .. Re3ulk lona of Be. <br /> Joa301p County Public Re(alttlr 9ery/c�ea. <br /> Job Addie.. // --- .r\�k ,�EL7/'L.aTTe� / City L.LI a/A<rlape <br /> Owner.Nons, YL)•OAC_ Address _ 4 4=7 ']_�OPhoone �i <br /> COnhac1,x S1Jz�.AA1nLL_Address yj� Icerfe No. '�_ �Pnane 3 S <br /> TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT .! DESTRUCTION D wt of Servlpe Wall ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR .❑ OTHER Li Ilonttorilrn well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OS WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I!Indust"( 0 Open Bottom ❑ m.ewo Oil of W.11 bcevabon ON. of Well Casing <br /> r l Dcmkv.c/Pirvale ❑ G,.,*Peck 0 Tracy Type of Casing_._— Soecrfiuuons <br /> 1'i Putter- ❑Other fl Dene Depth of Grout Seal Type of Grout \ <br /> i <br /> I I Ingatwn _Apryoa. Depth I I Eastern SuHau Saul Insullce by <br /> Raomi Work Dona Ll Type Of Pump H.V. Smut Work Dona_ <br /> wan Drul.cue. 0 won Camels Lkallry Ywterlal a Depth <br /> Depth Filler Hsterial i Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REFAIRIADDITION TRUCTION I I (No septic system pOrmdrad it Publ¢Fewer is ; <br /> avarloble within 200 feat.) f <br /> INmllelpn will MM: A�93jdsncs_ ComrMKNI Other <br /> Numbum <br /> er Of Wing tl:' Number of bedm <br /> roo . <br /> — Chasclsr of..n to•depth of 3 Eel 'l l Wno mGa dptn <br /> SEPTIC TANK (¢�/Mlp ca"city� j—{�` fL No.Comps.tnrnu <br /> PKG.TREATMENT ALT.0 ���-� Method of Onpyu1 <br /> Distance to nein- WITHoundsfwn I.5 Proper v Line J.SLV� <br /> LEACHING LINE 0 No,b Length of line Total length/Sire ( _ <br /> FILTER BED n Distance to nearer Well - Foundation _ Properly Line \\ <br /> SEEPAGE PITS 11 Depth Size r umber <br /> SUMPS _1 Oil:..to nares- Well Foundation Property Line ? <br /> DISPOSAL PONDS 0 <br /> 1 hera0y certify that I him proparN this application and that the work will be done in Accordance with Sen JoaQuin county Ordinance%, eels lows. no <br /> ru!u and raguhtrons of the Sae JpeOutc County <br /> HORN owner or I ci need&,iV u spNlWa conifer.tM following:'I eeRdy that In the prtormene of the work lot which this pernal is UNed.I Men not <br /> amobv any weon in such rnsnnr a to bacorn a orkman's compensation fowl of CMdorms."Contractor's hiring or wb­contrac Ong signature <br /> Cci fosowing: ' n mat in rho perl n e o nn_�l`r which this permit 1.issued.1 anaN employ PorWn,.ubiacl to workman's corh011 <br /> ion laws of r 4." t <br /> Tha epp'ican mustLisowing varFe aid r .� <br /> Spited Tit Data: <br /> L <br /> O DEP A'IITM FNT USE ONLY <br /> Application Accepted byf •�` `~� DSN Are. <br /> Pit er G,,n lespecflon by Due Final Inspection by Dna r/ <br /> Additional Commanis: <br /> Applicant - Return all copies to: San Joaquin County Public Health Servlcce <br /> EaVi roemental Health rermit/Service. <br /> 44b N San JoaRuln. P. Boa 2009, Stern, CA 0?211] <br /> EEE AMOUNT DUE AMO NT RSMIt TEO CWEO ev ATE PERMar <br /> :NFO Z <br /> J <br />