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k ir/J It <br /> � SAN\JOAQU N COUNTY PUBLIC 'H$ALTH SERVICES <br /> x — +4Z� =E►iViRONYENTAI; <br /> DIVISION--— <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P£I2MTT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby ade•to Ban JoeQuin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Bemc <br /> /e ///{//► <br /> Job Address ��� ��' `�' Cry <br /> Site/Acreage <br /> J r <br /> Ownei s Name //M Address ___( Phone <br /> Contractor Address nse No. Phone <br /> TYPE OF WELL/PUMP: i ' NEW WELL WELL REPLACEMENT .. 41 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTAL TI N SV T REPAIR OTHER❑ 'KonitoringWell ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES �POSAL FLO. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —.i <br /> INTENDED USE_ TYPE OF WELL _PROBLEM AREA _ CONSdTRUCTION SPECIFIC I S J �� 41 <br /> acrL)I ._. . _ _ <br /> Ll In trial pan Bonom ❑ Manteca iDja'.of We Eicivillor.� 'Dia:df�/Vall-Cilirlg "'^"'�•"'�'•� <br /> ptwnsttic/PrWeta C0 Gravei Pack ❑ Tracy f Ty-pi-of CaHb¢_ Specilicatons <br /> I"I PuDI'c n Other n Delta ,`Depth.of Grout.Seal Ty of Grow I <br /> rgatbn-'+--�'� t Approm. Da I I Eastern ..•SAaeD Sent Insulad by t ' " •N <br /> State Work Ocoe <br /> Repair Work Done ❑ Type of Pump O•P• ' <br /> ray <br /> Seel tial a Depth <br /> Wel Damnation ❑ We0 Diameter _ <br /> DeP11+�• Piller~1Gterial a Depth \��~• C- <br /> TYPE OF SEPTIC WORK: NEW.INSTAL AT10N I I`IiEPAlR7ATSD17_ION Iq 'DESTRUCTION I I (No teplid system pirmiiFed it public se r is <br /> �� ! zN - `_ '� available within 200 lem.1 <br /> Inaaladon�Mhwrfy� R�emtlOnea_ Comhrorcial_ Iuthar r - - <br /> Number of living units:_L_-"Number_of bedrooms •• <br /> Character of fall to a depth'-000 feat: I Water table depth 4 •r'ti.. <br /> SEPTIC TANK. ❑ ••Type/Mfg I ��- CapacityNo. Compartments <br /> PKG. TREATMENT PLT.O iy Method of Disposal I <br /> SDHtence to nearest: Well Foundation —Ptopeny Line } <br /> LEACHING LINE ❑I:No!a Length.of lines- 1 _ Total length/size t <br /> FILTER BED 11I Distance to nefrem: WellFoundation Property Lira <br /> i I <br /> SEEPAGE PITS 14 Depth; Sue Number <br /> SUMPS LI , Distance to naarM: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ <br /> _ I hereby certify that I hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin County <br /> j Home owner or licensed,egent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,11 shall not <br /> employ any person in such manner as.to 6ecoma subject to workman's compensation laws of Colifornia."ontractoK hiring or subcontracting signature,_. . <br /> ' certifies the following: "I certify the[i the partormenci of the work for which this permit Is Issued,I atoworkm <br /> ll employ poison&subject to an i compan". <br /> tan laws of Caiifornls.•• ; <br /> 4 the epdiu t tall for all re ea in coons. Complete drawing on to r &do. C. - ---- �"� <br /> t <br /> Title: Date: <br /> _ Signed 1 <br /> t F RDEPARTMENT USE ONLY <br /> I ��•'�.3 <br /> I <br /> Application Accepted by Area <br /> / Data1 <br /> PR or Gfou1 Inspection by _ Date to <br /> JL-q_?Final Inspection by Dau 1 <br /> M <br /> Additional Comments! <br /> I �.wvvvww'• <br /> Applicant - Return all copies to: San Joaquie County Public faith Services <br /> Environmental Health Perm t/Services <br /> 445 N San Joaquin O S 2009, Stkn, CA 95201 <br /> F�IN <br /> AMOUNT DUE AMOU T REM TTED N RECEIVED BY A P RMIT'NO. <br /> O ]AW <br /> . EN t}aa(RIV.v•m <br /> EM 14a1 i tCJ/ f 9 <br /> Y <br />