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it il <br /> fl <br /> A APPLICATION FOR PERMIT p�j4V <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r1AY <br /> F:NVIRONW NTAI, HEALTH Di VISION L <br /> i P 0 BOX 2005, STOCKTON, CA 9521�� , <br /> (209) 468--3447 `� i JC,'t- f it <br /> PEF3IISIT FZEIRES 1 YEAR fRUM DA1'Ii ISSUED <br /> (Complete in Triplicate) <br /> t <br /> Appllcatlon is hereby made to San Joaquin County for a permit to construct and/or Install the work herein descrlt> d. ThSe <br /> appltcat!oa Is ande In cotwltance with San Joaquin Ccunty Ordinance Ko. 549 and 1662 and the "- lea and fiegulatlons of San <br /> l Joaquln County Public Health Services.! 1 - <br /> ryrSL�� <br /> OJJot)rlaArd'odrNsosma City <br /> 1 L�ost�Slse/Acreage <br /> �� �TAddress <br /> Phone <br /> !I Contractor�� � _� Address <br /> TYPE OF WELLIPUMP. NEW WELL C1 WELL AEPLACCMENT I'. DESTRUCTION 0 Out of Service ell <br /> - PUMP INSTALLATION C� SYSTEM REPAIR e"}r OTHER ❑ Monitorlttg x011 L� <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT.iRE WELL OTHER WELL PITS,rSUMPS <br /> tNTENOED USE TYPE OF WFLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Intl trial U Open Bot:om 0 Manteca Ola. or Well Excavation -- Dia.of Weil Cooing <br /> rmeaticlPllwte ❑Gravel Paoli Q Tiozy Type of Cooing,„, — Specilketions <br /> i' Lh PuNc Il Other 0 Delta Dcrtn tat Graw Sea= ___ TYPO of(trout <br /> 0 Irrigation �_ _ Appros. Depth 0 Eastern Su,fice Seal Installed b%, <br /> _ W <br /> i Rlepair Work Done 4? Typo of Pump h`.P. � —..— Stns Work Done <br /> Well Destruction O Well Diameter Seallrsa Material a Depth <br /> E Depth�,..._ Tiller Material a Depth <br /> I� n TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AOOITLON❑ DESTRUCILQN❑ [No septic system pormiued if public Bowel Is <br /> I -f� r avulabre,wlh�rt 100 flsat.l <br /> installation will aervc Residence— Commercial— Other - <br /> i ,1 Number of living units: — Number of bedrooms <br /> l - Character of 504 to a depth of J feel:_ Water tab$e depth <br /> SEPTIC TANK 0 TyoelMlg _ Capacfty No.Companmente <br /> =^v' �u 1 PKG. TREATMENT PLY.0 Mathod of Disposal <br /> �P <br /> Distance to nearest: Well „• Foundation Propeny Line <br /> to <br /> i <br /> (r, LEACHING UNE C1 No.h Length of linea Total Ienythlsise <br /> fIITER BED CI D'ttancs to naafest: Well Foundation Property Lane <br /> SEEPACI-PITS I I Depth i <br /> ,! P .aSre Number <br /> SUMPS LI Dislance to nanel: Well ,�,, Foundation. _„ Property Lin <br /> `i�' DISPOSAL PONDS 11 <br /> `s x _i,t is ai °, i hereby canify that I have prepared this application and that the work will be done in eCCOrdance with San Joaquin county tsrdrnaMea, state fowls,and <br /> rules and regulations of the San Joaquin Cwnty <br /> Horns owner or licensed agent's signature certifies the toliow,ng: "I Certify that In the performance of the work for which this permit is Isaued,I shall net <br /> ' employ any rerson,in such manner as to become 4ublact to wCrkman't comoenution Laws or California,-COmraetor's hiring or sub-contracting eignsture <br /> Coriifiee the following:"I comity that in the penormsnce of tow work for which INN permit Is loured.I Malt employ persons"tgect w workman's compon4- <br /> tion taws of California.. - <br /> `l'' IE The applicant must tali aYrequired it;spe tions.Compete drawing on r"se side. , <br /> s , <br /> it �+I t <br /> � Signed?�„_ �G�,.=k Tltb:_ ���_ Dow-5- <br /> 1 <br /> s. <br /> ✓' i 1 'FOR DEPARTMENT USE ONLY <br /> �`` Application Accepted by � �1 C���� �, Oasa <br /> d,, rPit or grout Inapectlon by para_�„-,���• Finsl InaCection bv_�:.,e�•�.� '� bate <br /> Additional Comments. <br /> Applicant - Return all COPLOS tot SAN JOAQUIN COUNTY PUBLIC HEALTH 95AY[CES <br /> F.NYIHONN NTAL PI:ALTN DI,'1SIO01 PERU IT/:3F.HVIC&9' <br /> I <br /> 445 N SUI JOAQUIN, P J BOX 2009„ STOCKTON. CA 95201 <br /> '•'"Li(��, e. IN{G ttDUNT pts{ AMC WIT REMITTED CaScI RF[EIVFO fly Oa TF — PaRMITNC. <br /> IaFv..,.,I p/� �{ Cr� C 91-1226 ; <br /> -� <br /> r _ <br />