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A <br /> -� - APPLICATION FOR PERMIT o - - <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> * (209) 468-3 -M-50 <br /> PUM I T ELMAa-.3,_YEAR PM RATE LOU= <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described This <br /> application is nada in esNPliance with Sart Joaquin County Ordinance Bo 549 and 18112 and the Rules and Regulations of Ban <br /> Joaquin County Public Health / eJ <br /> Job Address&sag& M City 7Zee.4 Lot Oise/Acreage <br /> Ownses Nana nktiM2 <br /> SkPPL1 Af &� Address R 40, O r0ag Phone <br /> Conlractor,4Lityl� ddress st�3S A/ rKo L�crnse No ��Phone $ <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Q Out of Service Woe ' t. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER0 Monitoring Voll [7 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES — DISPOSAL FLO �/4PAOP 91 Litye- — <br /> FOUNDATION ,,. AGRICULTURE WELL _� OTHER WELL PIIT��S/SUMPS _. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom 0 Manteca Ois of WON Excavation Ora of Well Casing a <br /> fd[OornestrelPnvate 0 Grsvef Pack CK Tracy Type of Casing_ l.&Z& Specifications <br /> 0 Public SIF Other &kW4,6 O Delta Depth of Grout Seal ID Jo 5+[RF Type of Grout <br /> CI Irrplaton jW AWox Depth 0 Eastern SuAace Seat instsuod by AOiA 91k&sierr. '�;�4/'u� �` •- _• <br /> Repair Work Done L7 Type of Pump HP State Worm Dona_ <br /> Well Destruction O Well 04imet4w 4il"lieg Material i Depth <br /> Depth - ho,± eller Material A Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system++permitted of public sower is <br /> available within 200 feat 1 <br /> Instasation will serve Residence_ Commercial_ Other <br /> Number of Nwing un{ts Number of belroems <br /> Charecter of seat to a depth of 3 Not Water table depth <br /> SEPTIC TANK CJ Type/Mfg CapacityNo Compartments <br /> PK6.TREATMENT PLT.0 Method of Ottlposal <br /> Distance to nearest WON Foundation Property Line <br /> LEACHING LINE 0 No A Length of Mees Total lengthhUo <br /> FILTER BED 0 Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Sire Numb it <br /> SUMPS LI Distance to merest WON Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 have prepared thio applicallon and that the work wtp be done in accordance with San Joaquin county ordinances state taws and <br /> I rule and regulations of the San Joaquin County <br /> Nome owner or licensed,gena a signature cortin"the following 'I certify that in the performance of the work for which this parent is issued 1 shall not <br /> employ any person In such mistro t it ae to beaoms subject to workman a compensation taws 'it Caldomrua' Contractors hiring or sub-cortirecung signature <br /> certifies the following 'I certify 0*4}n the performance of the work for which this permit is issued I shall employ persons subject to workrren a componsa <br /> tion laws of"Norftlo." <br /> The epptiean o t (I for eA ittapeetlorn Complain drawing on mono tide (�,, � C � <br /> $ignod t TIt1e. _ "' -�- o Cay �"^"' Date' <br /> FOR DEPARTMENT LISP!ONLY <br /> ApplicetteR Accepted by 6��-~— Data 4'' Ane �r <br /> Pit or Gmv h apsaton by Data Final Inspection by Date <br /> Ilddltlonst Comments. <br /> APplleatlt - Retwra 611 eopiea tot BAN JOAQUIN COUNTY PUBLIC HEALTH SIIRVICBB <br /> ENVIRONMENTAL 92ALTN DIVISION PSRIIIT/SERVICSS <br /> 445 N SAN JOAQUIN, P O SOX MOOS, BTOCHTOM, CA 95201 <br /> INFa AMOUNT QUN AMOUNT REMITTED CK aAny C(IVED Ny DATE pERMlt NO <br /> tM 4aI <br />