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t 0 <br /> APPLICATIQN <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN PHONE(209)kt69-342t} <br /> P O BOX 388,STOCKTON,CA 95201-0388 <br /> REFIT�.. S IRES I YEAR FROM IDATL SSUED <br /> ( ple'" 112 Triplicilte) <br /> Application is hereby made.to San Joaquin County for a perntit.toctutstructand/or install the work herein described,.11his:application is made:ih Compliance with San <br /> Joaquin CountyDe 1-11203=,dl Section 9.1115.3 artd the Rules and RegularioI4of San3oaquin Coapty:PubJit Htaltlt:5crviccs. <br /> Job Address � _ fi>�� T f'� <br /> .. <br /> City �1..1•�._ Loc 5t..r./Aereag <br />' owner's Nameri'°, d '."n5 <br /> Address. . I Phone .: t oca`"' � <br /> ,,c - u�ftG ► C _ <br /> Address <br /> TYPE Of WELLtPUMP NEW WELL:❑ WELL REPLACEMENT Cl,gj DESTRUCTION C3 Out of Service Well Cl <br /> PUMfs 1NS7ALLATION SYSTEM REPAIR C1 E OTHER A Ift Well ❑ <br /> DISTANCE 7ti NEARESL SEPTfC TArNK: SEWIif.LINES —_ DISPOSAL FLS:.. PROP :LINE. <br /> 06t1Wt1ATlOfrf:. URE WELL OTHER WEL PITSJSUMP$ <br /> INTENDED USE TYPE OF WELL PROBLEM A99A.. CONSTRUCTION SPE&iCATt0.N5 <br /> 0 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia.pf lflfak <br /> ClDomesticll rivllte CI Gravel:Pack :0 Tracy Type of Casing, i. Specificatro <br /> i 1 Public f i Ottrer (1 Delta. Depth of Grout Seal ;! — i ype.pf Grout <br /> I I Irrigation. —.A0ptox.`.Oepth I I Easton) Surface Seal Installer! by <br /> Repair Work Dame ❑ Type:Of 0-urstp:: M.R; Stara Work Dona:.,_ <br /> Welt Destruction .0 Wall DiBrttetar Sealing Neterial & Depth <br /> Llapth.._ F311;sr lllaterial x Depth <br /> TYPE O1= SEPTIC YUi fi.K;. NE1fV.1kISTA1WION:I l REPAIRLIADDITION I I DES;TRUCTIf3N I I lNo septic system permit <br /> te;f rf public sewart:=ia: <br /> t9 <br /> available within 200 feet,) <br /> Installation will sarva ::Retfidenr"_. ;Comtrtial . Otfrer <br /> Number of living unit Numbar of bsd1V60ft:;,_ <br /> aractar stf soil to a+depth of 3#=+rats Water table depth <br /> SEPTIC TANK #=77 TVW.Mfg Capacity—0 No. Compartments <br /> PKG, TAEATMWT PLT;0. Method of Disposal t J <br /> Distance to nearest: Well Foundation " Pro <br /> Deity I:ttta � <br /> LEACHING UNE 0 No. & Length of lines To al lengthlsize <br /> FILTEfi REO d Distance to neareitt:L Well Foundation I>foperty Lina <br /> SEEPAGE plTS !1 Depth Size Number, <br /> SUMPS 11 Distance to rieuest. ML L Foundation Property Line <br /> DISPOSAL PONDS 0 l 1 <br /> I hereby certify that I have prepared this application and that the weak will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin County <br /> Moore owner or licensed agent's signature canifi s 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"f certify that in the performance of the work for which this permit is issued,I shall emoloy Persons subject to workman's compensa- <br /> tion laws of California:" <br /> The applicant If foradrequired i ns. Co plete_drawing on reverse side. <br /> Signed Title::_ V 1#rayl <br /> eta- <br /> <�%_.- fOR DEP111tTI1AEfifT USE ONLY �' � <br /> Application Accepter!by u� +it Qac 717 Area_ I <br /> t t <br /> Pit or Grout Inspeaion by Date Final Inspection t?y <br /> Additional Comments. ..5.,49 <br /> Applica,t: - Returp xll copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services r^, <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-(}388: <br /> tfEE AMOUNT t1tJh2 AMOUNT REMITTED CK C Sw RECEIttWilly DATE PERMIT NO,IM 13-24 IAVY, <br /> *� <br /> r <br /> EH 14-a ' <br />