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I <br /> APPLICATION ?3 5-&9 �vOUo '7S` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 y q� <br /> AI <br /> P 0 BOX 2009, STOCKTON, CA 95201 Apf _ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f!v � <br /> (Complete in Triplicate) <br /> Application is hereby made to Sew Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is Made in ewipliance with San Joaquin County Ordinance ho. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin county <br /> ,PPutlic Health Services. /J� <br /> Job Address 37 3, �- ��Af2 t�rzM- "� � City sf�. �av Lot Size/Acreage —t 7` f e c,- <br /> �" t 3 <br /> Owner's Name,� VVQ It Address _�s� S[1 �� _ _ �j//� Phone <br /> Confracltx/C �+ — �Ny` _Address- � �CfL��:I r�/� License No. 7'7`/ � Phone3 <br /> TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT F1 DESTRUCTION G Out of Service Well 0 <br /> PUMP INSTALLATION C1 SYSTEM REPAIR Li OTH 11166-11oring Well El <br /> DISTANCE TO NEAR SEPTIC TANK _ SEWER LIVES DISPOS PROP. LINE v <br /> ~ FO ION AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL 08LEM AREA C ION SPECIFICATIONS <br /> Ul Industrial ❑Open Bottom ❑ Mant Dia. Of Well Excavation_ Dia. of Well Casing <br /> Cl Domestic/Private ❑Gravel Pack :,7 y of Casing___ Specifications <br /> I"I Public f.? Other �7 Delta Depth of dt�eai Type of Grout <br /> I Iroodtion _A -Depth I I Eastern Surtace Sedi insrall <br /> Repair Work Done i] of Pump H.°- — State o e (J <br /> Well Destruction ❑ Well Diameter Sealing Material Z Depth <br /> Depth Filler Material i Depth <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I : DESTRUCTION I I (No septic system permitted if public sewer is <br /> avaelable within 200 feet.] <br /> Installation will serve: Residence,- Commercial Other R`t <br /> Number of living units: �_ Number of bedrooms (,2 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mig Y�. Capacity o7 o No. Compartments <br /> PKG. TREATMENT PLT.Ll f Method of Diapos.al <br /> Distance to nearest; Well/30 Foundation —Z--0Property Line_/A�r <br /> LEACHING UNE No. b Length of lines — _ Total length/size <br /> FILTER BED n Distance to nearest: Well Founastion — Property Line <br /> SEEPAGE PITS Depth �� Size �-77� rr Number. <br /> SUMPS Ll wi <br /> Distance to rrest: WelkFoundation 16T 'o Property Line: Oa"'t <br /> DISPOSAL PONDS 0 <br /> 1 hereby ctrtify that I have prepared This application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and.kegulations of the San Joaquin County <br /> Home oyrnsr or licensed agsnfa signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in au nna s to become subject to workman's compensation laws of Calilorrua."Contract oi's hiring or sub-contracting signature <br /> certifiat the f certify that ISN parfo nce of the work for which this perrnit is issued, I shall employ persons subject to workman's compensa- <br /> tion Is Calif nla. <br /> The plgicant m I req "ad ins omp ete drawing o��vt <br /> ersM4ife <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date T 13 Area <br /> Pit or Grout Inspection by Date/ .� Fingal Inspection by Deta 9 <br /> } Addltbn►i Comments: 6"13/t k+Ie_ W7 A. q �,W!; LvYli OfGGd/s y <br /> Applicant - Return all copies to: San Joaquin County Public Health Service <br /> III Environmental Health Permit/8ervices <br /> 445 N Han Joaquin, P O Box 2009, Stkn, CA 95201 <br /> I� FEE AMOUNT DUE AMOUNT REMITTED /J <br /> RECEIVED BY DATE J PIE M17 NO. <br /> INFO j CASH <br /> EM a-24 ISEv.1/MSI 5511 ! I�. .�� / / 1 `•a./ `� /�, /3 [f� <br /> IIEK 14-2a <br />