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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ' ENVIRONMENTAL HEALTH DIVISIOIN <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED /�� 1 <br /> (Complete in Triplicate) t�1` I` <br /> application is herety srde.to Son Joaquin County for a Permit to construct and/or ina411 the vork herein described. This ' <br /> application is made *In compliance vlth San Joaquin County Ordinance No. 51,9 and 1362 and the Rules and Regulations of San <br /> Joaquin County PFN 11c Health Services. <br /> Jon Address /.Y s /�/ y1 �7 �C'ily//n 'S Le/Acttag< � 7 I <br /> -i������ - �.� _� ��I� •rI'/ .7. /V'o fsf-rYR-�� Phgne 9/!v — 1,3? fl <br /> Owner's Name Address //�� <br /> Contracts / Address 913x"—,� dazaLA�sense No. � . Phone j <br /> TYPE OF WELL/ MP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ 4 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.❑ Monitoring 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 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> G Industrial ❑ Open Bottom, ❑ Mentors Dia. of Wall Excavation Die. of Well Casing <br /> I I Domestic/Private ❑ GreGsl Pack ❑ Tracy Typo of Casing_ Specihcatione <br /> r <br /> I'I PublicO Other fl Delia Depth of Grout Seal Type W Grout � ®1 <br /> r ! Irrigation —Approx. Depth I I Eastern Surface Seal Instsued�Dv w r <br /> Repair Work Done LJ Type of Pump H.P. Work Done_ <br /> Wall Destmow -O Wes DiametM Stealing Material Depths , <br /> ' Depth Tiller Material-4 <br /> TYPE OF SEPTIC WORK r NEW INSTALLATION ! 1 REPAIR/ADDITION TtL DESTRUCTION I I (No strain: sysraas permitted it ptrbf.c esryR is i <br /> / - available within 200 fest.) r <br /> Imtasation wNl servi:� <br /> Other -x <br /> V 6`or/Rrrrcial. r (\� <br /> .gyp <br /> Number of livirrp' tenth;- Number W <br /> CRMacter of soil to a daptlt of 3 feet: Water tab&,depth <br /> SEPTIC TANK. $- Type/Mtg a 4a o e4 Capacity - No. Cort pw~t, 2 7 1 <br /> PKG. TREATMENT PLT.❑ aaediod N Dopoaal 1 <br /> w u� f <br /> Distance to nearest: we" <br /> Foundation Z4 / Properly LineC1j <br /> t <br /> � "'"" <br /> t LEACHING LINE -cr+ro. 8 Largon o/IiMs - r tel length/aKe �� <br /> r FILTER BED EI Distance to rtasrest: WNI Foundation _ Property Line _ -1 <br /> 'a 1 <br /> SEEPAGE PITS 1)4 Depth �_� Sire 4 6 nrra"n umbar <br /> SUMPS LI Distance to nearest: Well Foundation Property Line ` /V <br /> bISPOSAL PONDS ❑ ri <br /> I <br /> 1 hereby certify that I have prepared this application and that the work will be dons in accordance with Son Joaquin county ordinances, state laws, and <br /> rulesAnd regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies this following: "1 certify that in the performance of the work for which this permit is issued, I"It not <br /> ornploy any parson in such rtrnnor"to bacor+r subject to woArman's compensation Jews of CsRlomie."Contractor's hiring or wb-contracting signature <br /> certifies the following:­1 cattily that in en*psdorma s of the work for which this pormit is issued,1 shelf ornploy Persons subject to workman's Cumpenta- <br /> tbn Jews of California." ` <br /> r <br /> The applicant asset calf for all regWrm3 I spacbsopla <br /> ns. Co te drawing on reverse side.Sig q p I <br /> �\^>��..d,.r tX/..Jh Title- Date: <br /> \ ' <br /> ,(t DEPARTMENT USE ONLY <br /> Apptica xin Accepted by Data �J `� Af}a <br /> �""��"" ,�D-�2l<t� Z ' <br /> P1 0.Orout Inspection w Dole Impaction wDate� f� 3 I <br /> f I <br /> Addntonal Commaro: - I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> �. Environmental Health Permit/Services <br /> 445 B San Joaquin, P O Box 2009, Stkn, CA 95201. j <br /> a <br /> EEE AMOVNT DUE AMOUNT REMITTED K { RECEIVED BY DATE PERMIT-NO. i <br /> INFO l 'CASH <br /> FH r}N faw. rhet 1 -Vo —UV 6 7,EdP - <br /> E 1Cat <br />