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n r" <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN C0UNT'9. PUBLIC RVIC � <br /> EN V I R0NMENTAL HEALTH I � �l <br /> 445 N SAN JOAQUIN, PHONE ( 3420 <br /> P 0 BOX 2009, STOCKTON, <br /> CAP A <br /> PERMIT LIPIRES I YEAR <br /> (Complete in Tripli aj� a..+ <br /> Application 1■ hereby wade to Dan Joaquin County for a permit W construct train descrlba4 This <br /> application Is made in compliance with Dan Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations o, San <br /> Joaquin County Publi Health Services. <br /> Q }�r <br /> Job Addreu �V �D t-�+'� ` C�ry>r�[` ={..- I'°t 91 ae/Acreage <br /> j Owrsr's NameAddress y 838E �➢ ��Lr Q w Pho -34-0165 <br /> y�� �-- <br /> k� AN - <br /> Address License No. Ptone <br /> TYPE OF WEL UM 6 NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION U Out of- service Mall <br /> { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ilnnitorling Well <br /> DtoTANCE TO NEAREST: SEPTIC'rANK SEWER LINES DISPCSAL FLS. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL .. OTHER WELL_ �M{jP-S�- <br /> 1'<TENCED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIF-:CATIONS pE�(('''� �►`/1�E� <br /> 0 Industrial ❑Open Bottom U Manteca Des.of WMI Excavation MR7Jid.' <br /> F)Do.7ielsoc/Private ❑Gravel Pack ❑ Tracy Type of Cesinp_ �_I Irsi6eafk <br /> I'I P,A%x C1 Other f1 De!ta Depth of Grout Soal SAN <br /> Hf Vl <br /> I I Irrigation Approx. Depth I I Eastern Surface 7erl Inas NPUBO <br /> ted by <br /> Repair Work De Type of Pup H.P. Stara Wb'rk b 41,1 J.SITA1 <br /> Done U m <br /> Well Destruction ❑ Well Diameter _ Dealing lhterial Y Gaptl. 4" <br /> Depth_ ____ liner Ifatarial i De <br /> pn <br /> x (� <br /> -� TYPE OF SEPTIC WORK: NEW INSTALt1+T1ON! I REPAIR/ DDffION DESTRUCTIO Ileo teplrC ayalerrm perrtvrted d plrblrc ar vat b <br /> r vsitable within 200 feet.! 09 <br /> Installation will serve: Remittence X Commercial�, other <br /> r Number of living tnha: Number o r t <br /> b d ton <br /> Character of moa to•depth of 1 lent:�7�''� �•i "� Water table depth <br /> SEPTIC TANK Type/Mfg S�Lt101 Y+_swcity at7Go) No. Compartments _ <br /> Q PKG.TREATMENT PLT.❑ f 1 Metfwd of 7isposal (� <br /> Distance to nearest: Wall�G Founds:bn 50'{' Property Line_�} <br /> LEACHING LINE No.8 Length of tines __ _ L'Y'-5_� Total length/aitsgo O <br /> _ FILTER BED ❑ Dictanea to nearest: Wolf„�pUti3•I Foundation �t��) �' Property Line <br /> a SEEPAGE PITS Dec1h —Si" _ _ Number <br /> SUMPS LI Distanca to newest: WallFoundauon f�O Property Line S r <br /> DISPOSAL PONDS O <br /> I MreDy grtity that 1 have prepared thin application and that the work will M dons M mccerdance with San Joaquin county ordinances,mtaW less,and <br /> rules and regAotionts of the San Joaq,im County <br /> z•+ Horth owner or kcensed agent's signature oert6so the following: "I certify that in the pariormance of the work tot which this pernwt It,issued,I"riot <br /> !r <br /> arTpby any perwn on such rrlanner as to become subject to workman's compensation laws of California."ContractlN■hiring a sub-untractirlg spnature <br /> cenfffe thisfoffowing:"I canify that M the peAormance of the work tow which this permit is isaued,I so <br /> hall employ persons subject to workman's cmpenu <br /> ? tion fawns of CWfa+lia." <br /> 1' r <br /> The tpp6com Twit far ad rrauired inspections Complete dewing on reverse side. <br /> trs n , f 7�4 <br /> b <br /> t C <br /> � l• '.Etle: �l �-Y <br /> A1-4 l� Data: 15 11 lrVt/t•94 <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> `•�c 4 i? Applkailon Accepted by - Date Area <br /> '►'\tit J <br /> Ph or Grout Inspection by Doze Final Inspection by Date <br /> r •�-� <br /> +.d AdWtbsu <br /> nal Comi n : - _ - r r <br /> Applicant - Return all copies to: San Joago: County /blit 6a Lits <br /> 9ervlcee <br /> Sovlronawntal Health Permit/9ervicne <br /> 445 N San Joaquin, P O !lox 2OO9, otka, CA 93701 <br /> IEE AMOUNT DUE AMOUNT REMITTED CASH RECErvfo Illy DATE PEAMIT'NO. <br /> *. ! [ INFO <br /> 17-Tr IaN-treat <br /> 1H l♦ <br /> :.1-2J <br /> IN la� <br /> WIL" <br /> sn <br />