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APPLICATION fl <br /> i SAN JOA,QUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH 'IVISION, <br /> 445 N SAN JOAQUIN, PHONE (2, 09)468-3420 <br /> P 4 BOX 2009, STOCKTON,' CA :9520 <br />( PERMI ESP YEAR FRtJ i DATE ISS-MM <br /> {COmol,O a in Tripli4ate) <br /> Application In hereby made.to Sass Joaquin County for a permit to construct and/or Ins tall the work herein described. This <br /> app13c4t10n is made in Compliance with San Joaquin County Ordinance No. 5h and 1662:and the Rules and Regulations or San <br /> Joaquin County Public Health Services <br />' Job:Address 404 >�!� �� � City- � Lot Size/Acreage <br /> !! <br /> 9vvr»r'a Name 0 W. J6-"+ TA144t'L JA -A2Phor� ��� 4141- 0131 <br /> -�----- <br /> Contractor it Address ►.. Vl 'c [.iG2nS2 Na. + Phone <br /> i TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT n .DESTRUCTION 0 Out or Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 O HER C7 Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC YANK Ir�rr,�T SEWER LINES 3r ;DISPOSAL FL,p. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL fiOTHER WELL , PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SOECIFICATIONS (,x <br /> 0.Industrial O Open Bottom 0 Manteca pie. of Well Excavatyan Dia.a!Weil Casing .. � J <br /> r.1 Domestic/Plivate El Gravel Pack 0 Tracy Type of Casing N,A 4APIPUAW Specifications :t <br /> I`I Public )P Other EMAP"In Delta. Depth of Grout Seat; T �� <br /> Type of_Grout_ <br /> I I Irrigation Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done C7 Type of Pump H.P. II State War pone <br /> Well Destruction. Woff Diameter , Sealing Material i Depth'r?. li+t <br /> Depth ifs / <br /> Filler Materiel A Depth <br /> TYPE'OF SEPTIC WORK, NEW INSTALLATION.I I REPAIR/AOOITION I I DESTRUCTION-I I (No naptic system permitted if public sower is <br /> availabW within 200 feet.) <br /> Instagation will serve: Rasidende w _ Corn erciaf_ Other <br /> I+lurtfbar o!living units: Number of bedroorns <br /> Character of so#to a depth of l fast. Water table <br /> SIsP I IC TANK:.. 13 Typalmio Capacity I. � No. Compsttmertts:. <br /> PKG.'TREATMEN PL7*.Cf Method of Diepotlai,. <br /> Distance td:..n" VIf811.. ... Foundation Property Line <br /> LEACHING LINE El Na. E' <br /> Total length/sire <br /> FiLTEl�81'D C1' Distance ta.:neacest; WeN Foundation. '� Property Line ., <br /> SEEPAGE PITS I l Dopth: Sire flNumbar <br /> SUMPS Ll Di�tancs to rtoarsst: we11 Foundation i Property Line , <br /> DISPOSAL PONDS i3 N i <br /> I hereby certify that I haws Drapers.that:apglicat 0n and:that the work will be done in accordancs with San Joaquin county ardinances, state laws, and <br /> rules and regulations of the$errfosquirf County <br /> Home owner or licensed ' <br /> a ents signature certifies the followin <br /> t# 9 9: "1 cen6fy that in.the perforl»ance of the work far whish this pem'tit.isissued, i shall not <br /> employ any person in such manner as to become wbject to Workmen's compensation laws of!California."Contractor's hiring to sub-contracting signature <br /> cartifies the following: "I certify that in the perfotmarjes of the Work for which Mie permit is Qed;I`she#employ persdim 4U.Nocll to vr41.6 n's comports• <br /> tion laws of California." <br /> The appi'cant m t required inspections. .Completo'drawing on reverse sing. <br /> Signed:' + titles 7✓lG fes- J"tI Date: 7 I <br /> FOR CFEPARTMENT;USE ONLY <br /> Application Accaptsd..byDate r Area <br /> Pit or Grout Ind by Clete Final Inspection by <br /> V., <br /> Additional Comments: IV Vv <br /> Applicant - 94t11rtt,a11 odpies to:: San Joaquin County Public Health Services ; <br /> Environmental Health Permit/sere ces A. <br /> 445 N San Joaquin, P Q Box 2009,IIStkn,.:QA :.9S <br /> 4FEE. 1 <br /> AM04NT OtfE: X#MOUNT Rt MlTTED RECEiYEI3 6Y BATE PEltI4tlf'Nip: <br /> INFIq� C]A,SH ,j i <br /> . e,t 1$•Sr 1NlEv.rlMm, <br /> Ek,4.2e <br />