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»:r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC ILSALTH SERVICES, <br /> ENVIRONMENTAL IiEALTS 71VISION <br /> P 0 SOX 2009, STOCKTON, CA 95201 <br /> (209) 463-3447 <br /> APR <br /> (Complete in Triplicate) CCn�tt��tnn.n,��'' 8 lsgi <br /> Application is hereby ssade.to San Joaquin County for a permit to construct and/or instal9 7nnorpp�� crlbed. This <br /> application In wade to compliance vith San Joaquin County Ordinance No. 549 and 1862 and th TJ 51t31dn■ of San <br /> Joaquin County Public Health Services. f, , �� � y/, <br /> Jab Address /SfrS )e6j LJp Y t't'� G+rY-sof Oat 8Lsc/Acreage <br /> ]wnr'sNama C„-rPcl (Ih'v( Address �j �'S� t Phone � ' <br /> Canlractar Atltlress � � 2 License No. S ZLG- Phone <br /> TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION u Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F ftonitoring well 'K <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION 1'5/ — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !r <br /> 0Industrial C]Open Bottom L-3Minifoa Gil.of Weill Excavown Dia.01 Well Caring <br /> CJ Oomostic/Private 0 Gravel Pack ❑Tracy Type of Casing, -_: 4-. _ — Spauficauona <br /> M Pubtie 1:1 Other ❑ Delta Depth of Grout Sea! _ /8 ' /S -- Type of Grout Ce f�f lam. <br /> a IrriUatron 1$ ,�E,,,.; ----1�Approx. Depth ;d Eastern Surface Seal installed by <br /> Repair Work pone L] Type of Pump H.P. Stele Work Done_ <br /> WIN Destrucbon Cl WeN Diameter Sealing flataria.1 6 Depth <br /> Depth 1111er Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/AODiT10N Cl DESTRUCTION EJ tNo septic sysum permntad if putNie fewer Ls <br /> available within 200 fast.l <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> C <br /> Character of aoA to a depth of 3 feel: —Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartment <br /> PKG.TREATMENT PLT.Ll Method of Oitpotal <br /> Distance to nearest: Wait Foundation ,_._ Property Lina <br /> LEACHING LINE Ll No.A Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Sias Number <br /> SUMPS LI Distance to nearest: Welf T Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I heraoy,candy that I have prepared this application and trial the work will be done in accordance wilh San Joaquin county ordinances,slate taws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner of licensed agent's signature cenifies the fotlewing:"I certify that in the performance of the work for which this permit is issued.I shall not <br /> employ any Patton in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> csrulies the Iollowing;"I certity that in the performs nce of the work for whicrt this permit is hated,I shalt employ parsons sublsct to workman's compensa- <br /> tlon taws of California." <br /> The applies uat al{for all required m c' s Complele drawing on revsaae side. <br /> Signed Title: Date:. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by LL Dat Ares <br /> _Pit OfGroutinspection by Data_Final Inspection by Date <br /> Additional Comments; <br /> Applicant - Return all Caples to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICE" <br /> 445 N SAH JOAQUIN, P O BOX 2009, STOCKTON, -''A 95201 <br /> 1 FEE AMOUNT DUE AA+.OUNT AEMiTTEO Cif RT�CIVE Ely LATE PERM11 NO. <br /> ;NFO <br /> E4 1771 IREV.-.1i. / Pill, <br /> EM:4ae <br />