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11 <br /> F <br /> ii <br /> Fi APPLICATION 29 70 <br /> SAKI JOAQUIN COUNTY PUBLIC i TAW, � <br /> ENVIRONJUNTAL HEALTH DI L <br /> F445 N SAN JOAQUIN, PHONE (2 9)� �. <br /> P O SOX 2009, STOCKTON, 11-AV5 p1 <br /> PERMIT EXPIRES 1 YEAR FROM A - I SUED <br /> F (Complete in Triplic t qq <br /> Apel. "'tioh is hereby made to San Joaquin County fora permit to construct and/or install the vork here ie <br /> application 3a m%de in ctsrgtllaace vith San Joaquin County Ordinance No. 549 and 1662 and the Ruies and Regulations of Sen <br /> Joaquin County public Health Ser ices. <br /> F1, .fob Address f City _�7 Lot Size/Acreege r <br /> Owners N24 <br /> -9.c�e7�C-c-C-yYL��Gc; _ Address yy Phone 3.3, - ? lT <br /> FConhaUor C9 �l- Address Z-/ phone <br /> TYPE OF WELL/PUMP: NEW WELL 1) WELL REPLACEMENT f] DESTRUCTIOWD Out of Service Well O <br /> ji PUMP INSTALLATION 0 SYSTEM REPAIR C) - OTHER O Monitoring Well <br /> f3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP.LINE — <br /> FOUNDATION AGRICULTLIR£WELL OTHER WELL PITS/SUMPS . <br /> INTENDED USE TYPE OF WELL PROBLEMARFA CONSTRUCTION SPECIFICATIONS <br /> r CI Indusinal Q Open Bolcom ❑Manteca Die_of Well Excavation Dia.of Well Casing <br /> [7 Domeslic/Private ❑Gravel Pack L3 Tracy Type at.Casing_ Specifications <br /> I'1 Public n Other - Fl Delta Depth of Grout Seal Type of Grout <br /> J I Imoatlon —Approx.Depth t 1 Esstem Surface Seal Installed by <br /> t y <br /> Repair Work Done L] Type of Pu - <br /> mP H.P. State Work Done_ <br /> Well Destruction Q Well Diameter Sealing Material i Depth - <br /> Depth Filler Material i Depth <br /> F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION lN'REPAIR/ADDITION I I DESTRUCTION I i 140 septic system permilled if publicsewer is <br /> Ineavailable within 200 feetinstallation will serve: Residence I- Commerc.t_ ther <br /> Number of gviitq unite: Number of opals <br /> /y1e// <br /> Character of sol to•depth of 3 legit;_t�L-r-C�. _yYater table depth ' <br /> SEPTIC TANK [It'Type/Mfg Ca cit OO1J <br /> ! � W y No.Compartments <br /> PKG.TREATMENT PLT.O <br /> _� Method of Disposal <br /> Distance to nearest Well. 3C I Foundation lit r Property Line o / <br /> i <br /> F LEACHING LINE - 4.L-No.6 Length of lines d ' / <br /> Tatar length/size -Z <br /> FILTER BED [[Z- Distance to deafest. Well f. 0 , Foundation-Y�2 f Property Line rl 3 / <br /> ��E_ <br /> SEEPAGE PITS IK-Depth : t ,Sire ,�!, <br /> Number <br /> 5UMPS LI Distance m nearest: Well /47-6 ' Foundation -D Property Lire s.73P/ <br /> DISPOSAL PONDS ❑ <br /> f <br /> D hereby certify that I have prepared this application and that the work will be done in accordance with San Jwsquin county ordinances,stege laws,and - ! <br /> rules and regulations of the San Joaquin County I� <br /> Home owner or licensed agent's aignelura certifies the following_"I cenify that in the performance of the work for which this permit is issued,I shell not it <br /> employ any person in such trmnner es to become subject to workman's compensation laws of California.-Contractor's hiring of sub contracting signature <br /> cenifies the following;"I cattily that in the performance of the work for which this pernut is issued,I shag smptoy persona subject to workman's compenaa <br /> Dian laws of Californis." <br /> r The apptict muss ell for 8117'red' ,lions.Complete drawing on ra tefse side. JJ / <br /> Signed Title- <br /> - <br /> {mac FOR DEPARTMEALT USE ONLY rr <br /> jl Application Accepted by �-^ jj + <br /> Date l Z Area <br /> it w Grout Inspection by pate <br /> .. - Final Inspection by <br /> Additional Conomenic j <br /> 'Applicant - Return all copies to: Sate Joaquin County public dealth Services <br /> Nnviroemen tel Health Permit/Services - <br /> 995 N San Joaquio, P O Box 2009, Stkn, CA 95201 I <br /> IF AMOUNT�DUE��� CK RECEIVED BY GATEFNFO CASH PFAMFT'NO. <br /> 3.4 WEV.trxll \f hs [�11. f" .?J'( S -1 <br />